Ob-Gyn Coding Alert

Find out what code to report for a "modified radical" abdominal procedure.

Last month, you learned how to use approach, uterine size/weight and extent to report hysterectomies -- but that's only part of your code selection process. To get these codes right every time, you've got to take into account additional procedures your ob-gyn may perform.

Begin With Burch Code Choices

First, when your ob-gyn performs a bladder and/or urethra fixation for stress incontinence in addition to a hysterectomy, you've got three coding options. And depending on the fixation point, your physician will refer to this as a "Marshall-Marchetti-Krantz," "Burch" or "Pereyra" procedure, says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M.

For an abdominal approach, you should use 58152 (Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]; with colpo-urethrocystopexy [e.g., Marshall-Marchetti-Krantz, Burch]).

For a vaginal approach, you'll use 58267 (Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy [Marshall-Marchetti-Krantz type, Pereyra type] with or without endoscopic control) or 58293 (Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy [Marshall-Marchetti-Krantz type, Pereyra type] with or without endoscopic control). Notice how you'll choose the correct vaginal approach code based on weight of the uterus: 250 grams or less, or greater than 250 grams.

Revisit Your Vaginectomy Options

Hysterectomies involving partial or total vaginectomies (colpectomies) have codes of their own.

For example, if your ob-gyn performed an open hysterectomy, you should use 58200 (Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube[s], with or without removal of ovary[s]).

Code 58200 represents removing the uterus as well as neighboring areas (the parametrium and uterosacral ligaments) and includes a partial vaginectomy. Ob-gyns perform this procedure when endometrial cancer has spread to the cervix or parametrium, Witt says.

Keep in mind: Code 58210 (Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling [biopsy], with or without removal of tube[s], with or without removal of ovary[s]) also includes a vaginectomy -- "upper one-third of the vagina, to be exact," Witt says.

If the ob-gyn performed this via a vaginal approach, you'll use either 58275 (Vaginal hysterectomy, with total or partial vaginectomy), 58280 (... with repair of enterocele), or 58285 (Vaginal hysterectomy, radical [Schauta type operation]).

Latch Onto These Lymph Scenarios

When an ob-gyn performs a para-aortic and pelvic lymph node sampling, he's performing a lymph node biopsy. He can perform this only via an abdominal approach. For this service, you'll report 58200. You'll see this service referred to as a "modified radical" abdominal. This includes a partial vaginectomy.

On the other hand, if your ob-gyn performs a bilateral pelvic lymphadenectomy and para-aortic lymph node sampling, you'll use 58210 for the abdominal approach.

Evaluate These Enterocele Repair Codes

Enterocele repair combination codes include hysterectomies. For a vaginal approach, you have:

• 58263 -- Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele
• 58270 -- Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele
• 58280 -- Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele
• 58292 -- Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele
• 58294 -- ... with repair of enterocele.

A vaginal hysterectomy with an abdominal enterocele repair, however, does not have a combination code, but ob-gyns would only do this rarely.

Test What You've Learned

Scenario: How should you code a vaginal hysterectomy with a uterus weighing less than 250 grams without the removal of tubes and ovary with enterocele repair and colpourethrocystopexy?

Answer: You have two options.

You'll report the vaginal hysterectomy with enterocele repair using 58270. You'll submit the simple anterior vesicourethropexy using 51840 (Anterior vesicourethropexy, or urethropexy [e.g., Marshall-Marchetti-Krantz, Burch]; simple). The Correct Coding Initiative (CCI) does not prevent you from reporting this code combination, and you have a better chance of receiving reimbursement with this option.

Alternatively, you could report the vaginal hysterectomy with colpourethropexy with 58267 (Vaginal hysterectomy, for uterus 250 g or less; with colpourethrocystopexy [Marshall-Marchetti-Krantz type, Pereyra type] with or without endoscopic control) and the vaginal enterocele repair as 57268 (Repair of enterocele, vaginal approach [separate procedure]).

According to the Medicare Physician Fee Schedule, the work relative value unit (RVU) for 58270 is 15.30 and 51840 is 11.36. That's a total of 26.66 work RVUs. Your second option's RVUs are as follows: 18.36 work RVUs for 58267 and 7.57 work RVUs for 57268. That's a total of 25.93 work RVUs. Based on these RVUs, you're better off reporting the first option.