Ob-Gyn Coding Alert

Knowing the new treatment options for endometrial ablation will allow you to more clearly assign the appropriate code and receive the proper reimbursement when your ob-gyn performs these new procedures.

In the past, when the ob-gyn could not control severe dysfunctional uterine bleeding with suction curettage or hormonal therapy, the patient's only option would have been hysterectomy. But in recent years, the surgeon has been able to remove entirely the endometrium that lines the uterus in some patients by using an electrode loop, a roller ball or a laser. In 1997, the U.S. Food and Drug Administration (FDA) approved the use of the first of many newer technologies that more quickly and safely perform the ablation in an outpatient or even office setting.

The first system the FDA approved was the Gynecare Thermachoice Uterine Balloon System (UBT). This procedure uses a thermal device designed to ablate the endometrium using a balloon that the ob-gyn inserts into the uterus with a catheter. A single-use balloon is attached to the end of the plastic catheter, which the physician inserts through the vagina into the uterus. Once it's in place, the surgeon inflates the balloon with 5 percent dextrose in water to a pressure of 160-180 mmHg. The solution is also heated to 87 degrees Celsius. The physician externally controls pressure and temperature. The ob-gyn leaves the balloon in place for up to eight minutes to coagulate the endometrium to a depth of approximately 5 mm. The doctor then removes the device, and the patient is observed briefly prior to being sent home. In accomplishing the procedure, ob-gyns can use a wide range of anesthetic from a general (when he or she performs the procedure in a hospital) to IV sedation to a paracervical block. In the past three years, the FDA has approved three additional techniques.

The Hydro ThermAblator System (HTA), approvedby the FDA in April 2001, uses heated saline to destroy the lining of the uterus. In this procedure, the physician dilates the cervix and inserts a small probe into the uterus that includes a tiny telescope (handheld hysteroscope) to visualize the uterine cavity while room-temperature saline solution is circulated through it. The fluid is then heated gradually to treat the uterine lining (the endometrium). The lining's change in color shows the effect of the treatment. At the completion of the treatment phase, cool saline solution replaces the heated fluid, and then the surgeon removes the instrument. Anesthesia can be a local, a paracervical block, IV sedation or general anesthesia.

Her Option Uterine Cryoablation Therapy System, approved by the FDA in April 2001, uses extremely low temperatures to freeze and eliminate the lining of the uterus. After local anesthesia is administered, the ob-gyn inserts a cryoprobe vaginally, through the cervix and into the uterus. Generally, the physician uses ultrasonic guidance to ensure correct probe placement and that enough of the endometrium is destroyed. Once the probe is in place, the cooling process begins, and the cryoprobe freezes tissue symmetrically around the probe tip. When the tissue reaches -15 to -20 degrees Celsius (+5 to -4 degrees Fahrenheit) or less, it will die. After several minutes, the physician warms the endometrium for one to two minutes then repeats the freezing. After a brief warming cycle, the procedure is complete.

The NovaSure Impedance Controlled Endometrial Ablation System, which the FDA approved in October 2001, uses lower-power electrical energy to cauterize or coagulate the lining of the uterus. After dilating the cervix, the surgeon inserts a bipolar electrode into the uterus. This electrode then expands to fill the dimensions of the uterine cavity. The system then insufflates the uterine cavity with carbon dioxide to check for cavity integrity and to ensure the device's proper placement. The by-products are then vacuumed out and, when the ablation is complete, the electrode retracts back into its sheath and is removed. Anesthesia for this procedure, in most cases, is a local.