Ob-Gyn Coding Alert

You are more likely to use A4562 because it represents silicone pessaries. Women fitted with silicone, rather than rubber, pessaries generally have fewer allergic reactions to the material. In addition, Medicare reimburses for A4561 (about $17) much lower than for A4562 (about $44), depending on where you practice.

Because the reimbursement for the pessary supply is usually lower than the price charged by manufacturers, many ob-gyn practices use the option of providing the patient with a prescription to purchase the pessary directly from the supplier and bring it to the office for insertion, Richardson says.

Medicare reimbursement is so low for pessaries because the law requires fees to be determined by using the average Medicare payment from 1986 and updating it by an annual factor every year, Richardson explains. In 1986, ob-gyns used mostly rubber pessaries, and the fees were based on these payments. CMS now devises the payments to reflect the different types of pessaries. The agency is aware that the reimbursement does not truly reflect the cost of the device and has informed providers that it is looking into the situation.

Sue Dooley, office manager for Pinelli Medical Practice in Jupiter, Fla., contacted her Medicare carrier, which told her a patient could purchase or order the device from the supplier. "That way, we are not selling the pessary to the patient, and the supplier or the patient can bill Medicare," she says.

You should remember, however, that for the patient to purchase the device from a supplier, she must have a prescription from the ob-gyn.

If you choose instead to provide the pessary to the patient, you can charge the patient for the device. But remember that Medicare Part B services are subject to a "limited charge" for providers who do not accept Medicare payment in full, so you should contact your local carrier to determine this limit.

CPT provides only one code for pessary insertion: 57160* (Fitting and insertion of pessary or other intra-vaginal support device). The asterisk after the code indicates that it has no global days under CPT rules, but this code also has a zero-day global period under Medicare rules. If a patient reports for her yearly examination and the ob-gyn decides to fit her with and insert a pessary during the same visit, you could still report 57160 in addition to the exam code. But remember to add modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M or preventive service code you are billing to indicate that it was separate and significant from the pessary insertion.

If the Medicare patient is eligible for her screening pelvic and breast exam, you should report both the pessary insertion and the screening exam using 57160 and G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination).

When the ob-gyn cleans and reinserts the pessary, you should code the appropriate E/M code for an established patient (99211-99215), depending on the examination and medical decision-making documented in the chart. You should use the pessary insertion code only once per specific pessary. If a new pessary is obtained and inserted, you may report 57160 again.

When billing the pessary codes, you should link them to the corresponding ICD-9 codes for genital prolapse:

Other codes within the 618.x family may apply based on the degree of prolapse or when the patient has combined uterovaginal prolapse.