Ob-Gyn Coding Alert

In a case of two potential coding options, you should factor in RVUs.

Remember how you factored in the ob-gyn's approach, uterine size/weight and extent to code hysterectomies last month? That's only part of the story.

You need to take into account additional procedures your ob-gyn may perform at the same time and how you should code them.

Hysterectomy With Stress Incontinence Procedure? Look at These Options

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, 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: 250 grams or less, or greater than 250 grams.

Hysterectomy With Vaginectomy? Check Out These Codes

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, but also includes a partial vaginectomy and he may remove some of the parametrial tissue. 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 would include removing the parametrial tissue since it is radical, and 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]).

Hysterectomy With Lymph Node Sampling? Underline These Codes

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 when also performing a hysterectomy. For this service, you'll report 58200. You'll also 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.

Ovarian or Endometrial Cancer Broadens Your Choices

When the physician is dealing with ovarian or uterine cancer, you should also inspect four other codes which might more accurately include the procedures performed. Your code choices would then be:

• 58951 - Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy
• 58953 - Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking;
• 58954 - Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy
• 58956 - Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy.

Enter These Enterocele Repair Codes Correctly

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 should never do this anyway.

Tackle This Hysterectomy Scenario

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 National 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 colpo-urethrocystopexy [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 25.05 and 51840 is 18.93. That's a total of 43.98 work RVUs. Your second option's RVUs are as follows: 29.79 work RVUs for 58267 and 13.77 work RVUs for 57268. That's a total of 43.56 work RVUs. Based on these RVUs, you're better off reporting the first option.