Ob-Gyn Coding Alert

What to do when hysterectomy note fails to specify vaginal or abdominal

When you-re coding hysterectomy reports, you cannot rely on the procedure's title. You must read the entire note carefully and highlight what the physician actually did. If you can't determine these things, you-ll have to ask your physician for more information.

To find out what makes a bad and good note and what to do about it, compare these two hysterectomy op reports and read the advice that follows.

 

Rate This Op Note

 

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

Procedure: The ob-gyn placed the patient in a lithotomy position and prepped the perineum and vagina in the usual sterile manner. The ob-gyn placed a tenaculum on the lip of the cervix and entered the cul-de-sac. He pushed the bladder off the cervix and the lower uterine segment. Then he entered the anterior cul-de-sac.

     
He clamped, cut and ligated both uterosacral and cardinal ligaments and the uterine vessels. He inverted the fundus of the uterus and then clamped, cut and tied the adnexal structures. He closed the peritoneum with a pursestring suture. He repaired the cystocele.

     
The procedure was concluded, and he inserted the vaginal packing. The patient tolerated the procedure, and the ob-gyn sent her to recovery in good condition.

 

Determine What You-re Missing

In this example, you-re missing vital information. For instance, can you tell if this is a vaginal or abdominal hysterectomy? Do you know if this is truly an anterior and posterior repair? The physician mentions that he does the repair, but he doesn't say that it's an anterior and posterior repair. He also doesn't say whether he removed the ovaries or tubes.

A bad procedure note leaves the coder with questions because the documentation does not resolve contradictory or conflicting information. -This can lead to a loss of payment or even overpayment,- says Christine Dubois, CPC, coding/compliance coordinator for Baystate OB/GYN in South Hadley, Mass.

     
Action steps: Get clarification from the physician immediately. -Doctors tend to forget that if it's not documented, it's not done,- Dubois says.

Good idea: Also, you may want to ask an experienced coder to explain what your ob-gyn generally does during a hysterectomy, so you-ll learn more about the procedure and what should be in the note.

 

Try Ranking This Second Op Note

 

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

 

Procedure: Under general anesthesia, the ob-gyn placed the patient in a lithotomy position. He prepped and draped the perineum and vagina in the usual sterile manner. He placed a tenaculum on the posterior lip of the cervix and entered the cul-de-sac without difficulty. He incised the cervical mucosa and reflected it circumferentially. He pushed the bladder off the cervix, and he entered the lower uterine segment and the anterior cul-de-sac.

     
He clamped, cut and ligated both uterosacral and cardinal ligaments, including the uterine vessels. He inverted the fundus of the uterus. He clamped, cut and doubly tied the adnexal structures. Inspection of the ovaries was negative. He closed the peritoneum with a pursestring suture.

The ob-gyn made an incision on the anterior vaginal mucosa down the midline from the vault to the submeatal area. He dissected the pubovesical cervical fascia from the mucosa and plicated across the midline with interrupted #2-0 Maxon mattress sutures, reducing a cystocele and restoring a urethrovesicle angle. He excised redundant vaginal mucosa. He tied the corresponding ligaments across the midline and anchored to the vaginal vault.

He gave attention to the posterior repair. He made a V-shaped incision from either side of the introitus toward the anus. He removed the intervening skin and mucosa and sutured the rectovaginal fascia across the midline. Using 0 Chromic catgut, he excised redundant posterior mucosa and closed with interrupted 0 Chromic catgut sutures.

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

 

Why This One's Better

You-ll find much more information here, particularly about the vaginal approach and the anterior and posterior repair, which is crucial for assigning the correct codes.

Bottom line: A good procedure note should be organized, have standard forms or recording information available and in a written or electronic format, be accurate, be legible, and use only approved abbreviations, experts say.

Based on this example, you should report these three codes:

      - 618.4 -- Uterovaginal prolapse, unspecified, for the pre/post-op uterovaginal prolapse diagnosis

      - 58260 -- Vaginal hysterectomy, for uterus 250 grams or less, for the procedure. Note: Neither operative report contains the uterus- weight, so you would choose the lesser code.

      - 57260-51 -- Combined anteroposterior colporrhaphy; multiple procedures.

 

Remember: You would append the multiple-procedure modifier to indicate to payers that this is a secondary procedure. In other words, you-ll -use modifier 51 on procedures that are multiple procedures performed at the same session by the same provider,- says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. Watch out: Some payers, such as Medicare, don't want you to use modifier 51 because their software recognizes multiple procedures.

           
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 or you could risk the procedure being denied for the use of an -unspecified- diagnosis code.