Ob-Gyn Coding Alert

Key: Approach is the first documentation detail you should look for.

Many ob-gyns perform female prolapse repair procedures at some point. These ventures into urogynecology can leave even the most seasoned coder scratching her head. Plus, changes in payer policies about when you can separately report mesh insertion adds an extra level of confusion.

But don't fret. Choosing the correct repair code is as simple as following this three-step path.

Step 1: Differentiate Anterior Colporrhaphy, Paravaginal Defect Repair

When a patient presents to your office with a prolapse of the anterior vaginal wall, which is commonly called a cystocele (618.01, Prolapse of vaginal walls without mention of uterine prolapse; cystocele, midline or 618.02, ... cystocele, lateral), your ob-gyn will perform either an anterior colporrhaphy or a paravaginal defect repair. Therefore, you'll have to choose between four procedure codes, based on the procedure your surgeon uses.

For an anterior colporrhaphy, use 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele). If the ob-gyn also repairs a urethrocele (618.03), you should not separately report its repair because it is included in the code description of 57240.

When the surgeon performs a paravaginal defect repair via an open abdominal approach, report 57284 (Paravaginal defect repair [including repair of cystocele, if performed]; open abdominal approach). For a paravaginal defect repair via vaginal approach, which is the most common approach, report 57285 (... vaginal approach). The standard indication for a paravaginal repair is a lateral cystocele (618.02).

For a laparoscopic approach, use 57423 (Paravaginal defect repair [including repair of cystocele, if performed]; laparoscopic approach), says Melanie Witt, RN, COBGC, MA, an independent coding consultant based in Guadalupita, N.M.

Step 2: Determine the Approach for Colpopexy

When a patient has a prolapse of either the uterus or the vaginal vault, your ob-gyn will likely perform a colpopexy, also known as a vaginal vault suspension. You have four colpopexy codes to choose from.

Choosing the proper codes means digging into the obgyn's documentation to figure out the surgical approach and where the ob-gyn anchored the suspending sutures.

Abdominal: If the ob-gyn uses an abdominal approach and attaches the vaginal vault to the sacrum, you should report the colpopexy with 57280 (Colpopexy, abdominal approach), Witt says.

Extraperitoneal vaginal: If the physician attaches the vaginal vault to the sacrospinous or iliococcygeus ligaments, you should report 57282 (Colpopexy, vaginal; extra-peritoneal approach [sacrospinous, iliococcygeus]).

Intraperitoneal vaginal: A third type of vaginal vault suspension involves attaching the vaginal vault higher up to the uterosacral ligament or to the levtor muscle complex. For this procedure, you would use 57283 (... intraperitoneal approach [uterosacral, levator myorrhaphy]).

Laparoscopic: If your ob-gyn incorporates a laparoscopic approach, you'll use yet another code. In this case, you'll report 57425 (Laparoscopy, surgical, colpopexy [suspension of vaginal apex]). The attachment site does not impact the use of this code, because it is the approach that controls the coding.

Step 3: Check for Rectocele, Enterocele Repair

Two other prolapse problems you might see cross your desk are rectoceles (618.04, Prolapse of vaginal walls without mention of uterine prolapse; rectocele) and enteroceles (618.6, Vaginal enterocele, congenital or acquired). When your ob-gyn performs a rectocele or enterocele repair, you have additional procedure coding options to review.

Difference: A rectocele repair is the repair of a prolapse of the back wall of the vagina between the vagina and the rectum. Basically, a rectocele occurs when the end of the large intestine (rectum) pushes through the back wall of the vagina causing vaginal prolapse. An enterocele repair, on the other hand, is the repair of a small bowel prolapse, which occurs when the small bowel pushes against and moves the upper back wall of the vagina.

For a rectocele repair, most ob-gyns perform a posterior colporrhaphy. For this type of procedure you have three coding options, depending on whether it is a single repair or a combined repair. These codes are:

• 57250 -- Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy
• 57260 -- Combined anteroposterior colporrhaphy
• 57265 -- ... with enterocele repair.

Note: Some general surgeons will instead repair the rectocele, which is causing fecal incontinence by plicating the rectal mucosa. For this procedure, the general surgeon's coder would report 45560 (Repair of rectocele [separate procedure]).

When coding for the repair of an enterocele without also repairing a cystocele and the rectocele, you must determine whether the ob-gyn used an abdominal or a vaginal approach. If the approach is vaginal, the technique he used will impact your coding choice. For the vaginal approach, report 57268 (Repair of enterocele, vaginal approach [separate procedure]) if the surgeon obliterates the enterocele using pursestring sutures.

If the surgeon instead performs a McCall culdoplasty to repair the enterocele by attaching sutures to the uterosacral and/or cardinal ligaments, report 57283 (Colpopexy, vaginal; intra-peritoneal approach uterosacral, levator myorrhaphy). "The purpose of the colpopexy is to support the vaginal vault, but in the process an existing enterocele is repaired and therefore this code is still appropriate to report when only the enterocele is repaired in this manner," Witt says.

For the abdominal approach, report 57270 (Repair of enterocele, abdominal approach [separate procedure]).

Important: Be aware that because CPT® labels codes 57268 and 57270 as a "separate procedure," the Correct Coding Initiative (CCI) bundles them into most other procedures. Check your individual payer rules before billing these codes separately if your ob-gyn also performed a cystocele or a rectocele repair as an additional procedure.

ICD-10: When your coding system changes in 2013, you should look to the "N" section of your manual, as follows:

• 618.01 will become N81.11 (Cystocele, midline).
• 618.02 will become N81.12 (Cystocele, lateral).
• 618.03 will become N81.0 (Urethrocele).
• 618.04 will become N81.6 (Rectocele).
• 618.6 will become N81.5 (Vaginal enterocele).