Ob-Gyn Coding Alert

You may have to wait for the path report to know whether to code fibroid or polyp

If you-re reporting uterine fibroid removal, you need to know two things:

1. Where the fibroid was located, so you can choose the diagnosis code.

2. What method the ob-gyn used to take care of the growth.

Simplify this complicated coding scenario by following two easy steps. You-ll know where to look in both your ICD and CPT manuals before the fibroid report lands on your desk.

Step 1: Make the Fibroid-vs.-Polyp Distinction

Fibroids and polyps are similar because they-re both growths, but one occurs in the endometrial lining while the other occurs in the muscle. Can you guess which one is which? Here's the answer.

Polyps are small growths on the surface of the uterine wall that are easy for the ob-gyn to remove. In other words, -they are an overgrowth of the endometrial lining,- says David Glassman, DO, assistant program director and assistant director of Women's Health Service, Department of Obstetrics and Gynecology at Banner Good Samaritan Regional Medical Center in Phoenix. -They-re intracavitary lesions.-

Fibroids (or myomas) are larger and are usually imbedded in the smooth muscle of the uterine wall. -They are almost always benign, but in rare circumstances, they can become a sarcoma (muscle cancer),- Glassman says. These growths require more work to remove, hence the procedures associated with fibroids tend to have higher relative value units (RVUs).

Fibroids form in three main locations:

- Submucous fibroids (218.0) grow from the uterine wall toward the uterine cavity. They are also called intracavitary fibroids.

- Intramural fibroids (218.1) grow within the uterine wall (myometrium). They are also called interstitial fibroids.

- Subserous fibroids (218.2) grow outward from the uterine wall toward the abdominal cavity. They are also called subperitoneal fibroids.

If the physician does not specify the location of the uterine fibroid, assign 218.9 (Leiomyoma of uterus, unspecified) as the diagnosis.

Important: You should report fibroids based on size, location (the fourth digit), and number, Glassman says.

Key strategy: Sometimes, ob-gyns may have trouble distinguishing between a small fibroid and a large polyp, but -they do have different appearances and textures when visualized during the procedure,- Glassman says. If you don't have enough to choose your ICD-9 code, you may need to wait for the pathology to return for a final diagnosis (a delay of 10 days or so).

Step 2: Know Fibroid Removal Methods

Treating fibroids sometimes includes surgery. By learning more about each method of fibroid treatment, you will be prepared for whatever your ob-gyn chooses to perform.

A. Hysterectomy Is Most Common

First, if the ob-gyn removes the uterus entirely, he performed a hysterectomy. This is the most common option, but only when the fibroids are causing problems, such as abdominal pain or heavy bleeding. Without removal of the uterus, recurrence of fibroids is common. The code assignment will depend on the type and extent of the hysterectomy.

Coding example: Because the patient is older than 50 years and has multiple fibroids, your ob-gyn performs a total abdominal hysterectomy (58150, Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]). You would not code the fibroid removal separately if the ob-gyn is removing the uterus.

B. Hem in Your Hysteroscopy Choices

Second, an ob-gyn may treat a patient with fibroids with a hysteroscopy. Hysteroscopic submucous resection removes a portion of the protruding fibroid and preserves fertility.

The hysteroscopic procedure requires -the close monitoring of distention media, electrosurgical devices, as well as a patient's anatomy to avoid perforating the uterus,- Glassman says. -Ob-gyns usually perform this straightforward approach for intracavitary (submucosal) fibroids.-

Coding example: Your ob-gyn removed polyps and fibroids by hysteroscope. The pathology diagnosis is fibroid. You should report 58561 (Hysteroscopy, surgical; with removal of leiomyomata) -- unless the ob-gyn also performed a dilation and curettage (D&C). If the ob-gyn did, you can bill both 58561 and 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C).

C. Master Myomectomy Codes

Another option is a myomectomy (58140-58146). A myomectomy is the removal of uterine fibroids only, which preserves fertility.

Coding example: The ob-gyn sees a 32-year-old patient who has never had a child but would like to. She complains of heavy menses with anemia.

On examination, the physician finds a 15-cm uterus with multiple fibroids that distort the endometrium. Because the patient wishes to have children, she elects to have a myomectomy, which the ob-gyn performs using an abdominal approach. The pathology report shows six intramural myomas.

For this case, you should report 58146 (Myomectomy, excision of fibroid tumor[s] of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams, abdominal approach) with 218.1, says Cheryl Ortenzi, CPC, billing and compliance manager for BUOB/Gyn in Boston.

D. Make Use of 2007 UAE Option

Finally, you may see more uterine fibroid embolization or uterine artery embolization (UAE) procedures. This is a nonsurgical, minimally invasive procedure that will shrink the fibroids by cutting off the blood supply.

The ob-gyn inserts a catheter through an artery in the leg to the arteries in the uterus. The physician then inserts tiny particles of plastic or gelatin through the arteries to block the blood flow inside the fibroids. Without blood flow, the fibroids shrink or may even disappear over time.

You-ll report this service using the new 2007 code 37210 (Uterine fibroid embolization [UFE, embolization of the uterine arteries to treat uterine fibroids, leiomyomata], percutaneous approach inclusive of vascular access, vessel selection, embolization, and all radiological supervision and interpretation, intraprocedural roadmapping, and image guidance necessary to complete the procedure).