Ob-Gyn Coding Alert

Use this modifier when radiologists report the same code.

Is your ob-gyn working with a radiologist to perform uterine tandem services? You have two codes at your disposal — but be careful. These tricky claims rely upon the correct use of a modifier.

Tip 1: Identify Key Terminology

Ob-gyns perform brachytherapy, which is the application of a radiation source to cancerous tissue, for early- stage cervical cancer or endometrial cancer.

For cervical cancer, an applicator called a tandem and ovoid delivers radiation. A tandem and ovoid applicator consists of a hollow metal tube (the tandem) that the physician inserts through the cervix into the endometrial cavity. The tandem is about 10 inches long and is as thin as a pencil.

The ovoids are hollow metal capsules small enough to fit in the vagina, up against the cervix. The ovoids have tiny radiation shields in them to reduce the radiation doses to the bladder and rectum. The patient then undergoes radiation therapy through the tandem and ovoid applicator by the physician placing radioactive capsules inside the hollow portions of the applicator.

For uterine cancer, ob-gyns place Heyman capsules instead (especially when the uterus is very large). Similar to the tandem and ovoid application, the ob-gyn places the Heyman capsules in the uterine cavity. They too are loaded with radioactive material. By placing the empty cylinders and capsules in advance of introducing the radioactive element, the ob-gyn limits exposure to unsafe radiation for surrounding tissue.

The ob-gyn may also decide to first place a hollow plastic tube custom fitted to the uterine cavity. He inserts this sleeve through the cervical opening into the uterus and sutures it in place onto the cervix. The purpose of the sleeve is to keep the cervix open, which allows for more comfortable and reproducible placement of the uterine tandem or Heyman capsules. In other words, the ob-gyn may have inserted and removed the tandems or capsules several times over the course of the patient’s treatment.

“The procedure takes about 20-30 minutes of operating room time,” says Chris Buttrick, CPC, coding and reimbursement specialist for Cleveland Clinic Foundation in Cleveland.

Tip 2: Determine What Insertion Involved

The codes you have at your disposal for these procedures are 57155 (Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy) and 58346 (Insertion of Heyman capsules for clinical brachytherapy).

Scenario 1: A 49-year-old patient with stage 2 B cervical cancer has completed her external beam radiation. The physician schedules her for tandem and ovoid placement for brachytherapy to complete her radiation therapy. The patient gets into the lithotomy position. She is prepped and draped. The physician dilates the cervix using Hegar dilators and sounds the uterus.

The physician inserts a tandem into the uterus. The other end protrudes through the vaginal opening. He packs the ovoids on either side of the cervix to protect the bladder and rectum from radiation. The radiation oncologist loads the radioelements into the cylinders at a later time to deliver a high dose of potentially curative radiation to the cervix from an intracavitary location.

Solution: Because this example describes the insertion of a tandem into the hollow cylinder, you should use 57155.

Scenario 2: Your ob-gyn diagnoses a 72-year-old patient with uterine cancer. She is not a candidate for surgery because of her severe cardiac disease, so the ob-gyn decides to treat her cancer with radiation therapy, including clinical brachytherapy. He schedules the patient for Heyman capsule insertion.

The patient gets into the lithotomy position and is prepped and draped. The physician dilates the cervix using Hegar dilators and sounds the uterus. Because of the patient’s uterus size, the physician inserts six capsules. Long tubes connect the capsules to the outside of vaginal outlet. The radiation oncologist will apply the radioactive element through these tubes into the capsules at a later session.

Solution: Because this example describes the insertion of Heyman capsules, you’ll report 58346.

Keep in mind: A radiation oncologist will perform the supervision of the radioelements and dose interpretation, while another physician will insert the empty tandems, ovoids or capsules. These latter tasks usually take place at a different session and require significant time and expertise. Therefore, you will usually not append modifier 62 (Two surgeons) -- unless the radiation oncologist and ob-gyn perform these services during the same session. If that’s the case, according to the Medicare Carriers Manual (MCM), section 14046, each surgeon will receive 62.5 percent of the Medicare Physician Fee Schedule Database fee indicated for their service, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.

But what if your ob-gyn inserts a sleeve into the uterus prior to putting in the tandems and ovoids or the Heyman capsules? CPT has no specific code for this procedure, but “the Society of Gynecologic Oncology (SGO) suggests we should report 57155-52 (Reduced services),” Buttrick says. If the radiation oncologist is the one putting in the empty tandems and ovoids, however, he would also be billing the same code, but without the modifier -52. This can create a reimbursement problem. In that case, you should consider using the unlisted-procedure code for the sleeve placement (58999, Unlisted procedure, female genital system [nonobstetrical]).

Tip 3: Remember CPT 2008 Development

CPT 2008 created a new subsection for reproductive system procedures and established the first code in this section, which affects ob-gyn oncologists.

In some types of gynecological cancer, radiation therapy may consist of both internal and interstitial radiation brachytherapy. You can now report 55920 (Placement of needles or catheters into pelvic organs and/or genitalia [except prostate] for subsequent interstitial radioelement application) in addition to codes for the placement of uterine tandems or vaginal ovoids (57155) or Heyman capsules (58346) for clinical brachytherapy. The code description indicates that if the physician places the needles in both pelvic organs and the genitalia, you’ll only report the code once.