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 [...]