Ob-Gyn Coding Alert

Relying on the title of your hysterectomy report could spell disaster.

Last month, you learned how to handle hysterectomy combinations in the article “Part 2: How to Make Sense of Your Hysterectomy Combo Claims.” This month, you’re going to examine documentation.

Learn why relying on the title of your hysterectomy report to choose your code is a potential mistake. Compare these two hysterectomy operative reports and learn what makes a good and a bad note — and what to do about it.

Do You See What’s Wrong With This Documentation?

Preoperative diagnosis: Uterovaginal prolapse Postoperative diagnosis: Uterovaginal prolapse Operation: Hysterectomy; anterior and posterior repair

Procedure: The patient was placed in a lithotomy position, and the perineum and vagina were prepped in the usual sterile manner. A tenaculum was placed on the lip of the cervix, and the cul-de-sac was entered. The bladder was pushed off the cervix and the lower uterine segment and the anterior cul-de-sac was entered. The uterosacral and cardinal ligaments and the uterine vessels were clamped, cut and ligated. The fundus of the uterus was inverted, and adnexal structures were clamped, cut, and tied. The peritoneum was closed with a purse-string suture. The cystocele was repaired. The procedure was concluded, and vaginal packing was put into the vagina. The patient tolerated the procedure and was sent to recovery in good condition.

Why This Example Is a Bad Op Note

You cannot determine whether this is a vaginal hysterectomy or an abdominal. The physician left a whole piece of the operation unstated.

Moreover, you only have minimal documentation of the repair, but you don’t know if it’s an anterior or posterior repair, says Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, New Mexico. You also don’t know whether they removed any ovaries or tubes. You have several potential codes in the 572xx code range, and without the detail you can’t compliantly select a code.

In other words, you must have your doctor document this information so that the documentation supports what you bill.

You should review any addendum reports.

If you still have questions, get clarification from the physician immediately. Your physicians should know that they can maximize their reimbursement for the work they did if they have good documentation. They should also understand that coding and billing staff will be coming directly to them for clarification when the notes do not make sense or have missing words.

Also, ask an experienced coder to explain what’s generally done during a hysterectomy so you’ll learn more about the procedure and what should be in the note.

Beware: You shouldn’t code simply from the procedure title section. “You have to compare the title and the procedure detail to accurately report your provider’s services,” Witt says.

Always read the whole op note, experts say. Don’t be tempted to only read the pre-op and post-op diagnosis and the type of operation the physician performed — you can easily miss details and other billable services the doctor did not include in the summary.

What Makes This Good Documentation?

Preoperative diagnosis: Uterovaginal prolapse Postoperative diagnosis: Uterovaginal prolapse Operation: Vaginal hysterectomy; posterior colporrhaphy

Procedure: Under general anesthesia, the patient was placed in a lithotomy position. The perineum and vagina were prepped and draped in the usual sterile manner. A tenaculum was placed on the posterior lip of the cervix, and cul-de-sac was entered without difficulty. The cervical mucosa was incised and reflected circumferentially. The bladder was pushed off the cervix, and the lower uterine segment and the anterior cul-de-sac were entered. The uterosacral and cardinal ligaments including the uterine vessels were clamped, cut, and ligated. The fundus of the uterus was inverted, and the adnexal structures were clamped, cut, and doubly tied. Inspection of the ovaries was negative. The peritoneum was closed with a purse-string suture.

Attention was then given to the posterior repair. A V-shaped incision was made from either side of the introitus toward the anus. The intervening skin and mucosa were removed, and the rectovaginal fascia was sutured across the midline. Using 0 chromic catgut, redundant posterior mucosa was excised and was closed with interrupted 0 chromic catgut sutures.

The procedure was concluded by repeated suturing of the mucosa in the perineal body, and the overlying skin was closed with continuous #3-0 Vicryl. Vaginal packing was placed. The patient tolerated the procedure well. Estimated blood loss was less than 500 mL. Sponge count was correct. The patient was sent to the recovery room in good condition.

Why This One’s Better

You clearly have much more information here, particularly about the vaginal approach and the posterior repair, which are crucial for assigning the correct codes. You can

also tell that the physician did not remove the tubes and ovaries because the physician did not cut the infundibulopelvic ligament, a prerequisite to removing the ovaries.

Tips: A good procedure note should be organized, have standard forms or recording information available in a written or electronic format, be accurate, be legible, and use only approved abbreviations. In other words, a good op note should follow the physician’s hands through the procedure.

You should report the above example with:

• N81.4 (Uterovaginal prolapse, unspecified) for the pre/ post-op uterovaginal prolapse diagnosis
• 58260 (Vaginal hysterectomy, for uterus 250 g or less) for the procedure. Neither note contains the uterus weight, so you would choose the lesser code
• 57250-51 (Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy; multiple procedures). You would append the multiple-procedure modifier to indicate to payers that this is a secondary procedure.

Keep in mind: Even the best examples still might need further information from the ob-gyn. In this case, the diagnosis could use further clarification. Otherwise, you risk the insurer denying the procedure due to an “unspecified” diagnosis code.

Documentation Tips

You’ve read about what makes a good and bad op report, but here’s what you can do to make sure you’re reading the documentation correctly every time:

• Read the note all the way though to see if the title of the procedure matches the note. Always code from the note, not the title.
• Highlight the procedures the physician performed. If you have trouble understanding anything, ask the physician to explain.
• Assign codes.
• Check for any modifiers that might be appropriate and check the National Correct Coding Initiative (NCCI) edits for bundled codes.
• Have a colleague check your codes for accuracy.

Remember: Take your time. You’ll stand a better chance of getting it right the first time and avoiding denials and appeals that may result from carelessness.