Ob-Gyn Coding Alert

Are you confused by when to report vaginal prolapse repair codes alone and when to report them together? The solution is two-fold: the exact type of prolapse (cystocele, uterine or vaginal vault, rectocele, or enterocele) and the ob-gyn's surgical approach.

Scenario: A patient may present to your office with a prolapse of the anterior vaginal wall, which is commonly called a cystocele (618.01, Prolapse of vaginal walls without mention of uterine prolapse; cystocele, midline; or 618.02, Prolapse of vaginal walls without mention of uterine prolapse; cystocele, lateral).

-- ICD-10: When your diagnosis code system changes:

Code 618.01 will become N81.10 (Cystocele, unspecified) or N81.11 (Cystocele, midline).

Code 618.02 will become N81.12 (Cystocele, lateral).

Your physician will perform either an anterior colporrhaphy or a paravaginal defect repair, so you'll have to choose between two procedure codes.

For an anterior colporrhaphy, use 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele). If the ob-gyn also repairs a urethrocele (618.03), you should not separately report the utherocele repair because it is included in 57240's code description.

-- ICD-10: Code 618.03 will become N81.0 (Urethrocele).

Bonus: During some anterior colporrhaphy procedures, the surgeon will add mesh to strengthen the repair, says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M. You should report the mesh insertion using +57267 (Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site [anterior, posterior compartment], vaginal approach [List separately in addition to code for primary procedure]). This add-on code requires no modifier or fee reduction and carries 7.16 relative value units (RVUs). That's about $258.37, based on a $36.0846 conversion factor.

Important: All payers look for a procedure's medical justification and add-on codes are no exception. The purpose of the mesh is to shore up vaginal wall fascia that is weak or attenuated, where sutures are inadequate to complete the repair. Therefore, look for documentation that indicates this, and report 618.81 (Incompetence or weakening of pubocervical tissue) or 618.82 (Incompetence or weakening of rectovaginal tissue).

-- ICD-10: Code 618.81 will become N81.82 (Incompetence or weakening of pubocervical tissue). Code 618.82 will become N81.83 (Incompetence or weakening of rectovaginal tissue).

Paravaginal defect repair coding hinges on the obgyn's approach. You've got three different options:

When the surgeon performs a paravaginal defect repair via an open approach, report 57284 (Paravaginal defect repair [including repair of cystocele, if performed]; open abdominal approach).

For the vaginal approach, report 57285 (Paravaginal defect repair [including repair of cystocele, if performed]; vaginal approach).

For a laparoscopic approach, use 57423 (Paravaginal defect repair [including repair of cystocele, if performed], laparoscopic approach), Witt says.

Beware: The Correct Coding Initiative (CCI) bundles the Burch procedure, anterior colporrhaphy, and enterocele repair with the paravaginal defect repair, so you cannot report these procedures separately. You also can't report 57267 for a mesh insertion with 57284 or 57423 even though it is not a CCI bundle, Witt says. "This is because CPT specifically cites the codes that can be billed with an add-on mesh, and CMS does not normally create bundles for code combinations that are clearly spelled out in CPT," she adds.

If a patient has a prolapse of either the uterus or the vaginal vault, your physician will most likely perform a vaginal vault suspension, called a colpopexy. How the surgeon approaches the problem and where he anchors the suspending sutures determine which code you should use to report the procedure.

Abdominal: If the ob-gyn uses an abdominal approach and attaches the vaginal vault to the sacrum, you should report the colpopexy with 57280 (Colpopexy, abdominal approach), says Teri Johnson, CPC, an ob-gyn coding specialist at the University of Minnesota Physicians in Minneapolis.

Transvaginal: If the physician uses a transvaginal approach, you should report 57282 (Colpopexy, vaginal; extra-peritoneal approach [sacrospinous, iliococcygeus]).

Intraperitoneal: A third type of vaginal vault suspension involves an intraperitoneal vaginal approach. For this procedure, you would use 57283 (Colpopexy, vaginal; intra-peritoneal approach [uterosacral, levator myorrhaphy]).

Laparoscopic: If your ob-gyn incorporates a laparoscopicapproach, Witt says you'll use yet another code: 57425 (Laparoscopy, surgical, colpopexy [suspension of vaginal apex]).

Don't report the addition of mesh using +57267 with the colpopexy codes because you can use +57267 as an add-on code only with:

45560 (Repair of rectocele [separate procedure]), 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele), 57250 (Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy), 57260 (Combined anteroposterior colporrhaphy), 57265 (... with enterocele repair), or 57285 (Paravaginal defect repair [including repair of cystocele, if performed]; vaginal approach).

Two other prolapse problems your physician might repair are rectocele (618.04, Prolapse of vaginal walls without mention of uterine prolapse; rectocele) and enterocele (618.6, Vaginal enterocele, congenital or acquired), and each has its own procedure code options.

-- ICD-10:When your diagnosis code system changes: Code 618.04 will become N81.6 (Rectocele). Code 618.6 will become N81.5 (Vaginal enterocele).

Rectocele: A rectocele repair is the repair of a prolapse of the back wall of the vagina between the vagina and the rectum. For this procedure, report 45560 (Repair of rectocele [separate procedure]) if the physician doesn't repair the rectocele by performing a posterior colporrhaphy. If he performs the repair with a posterior colporrhaphy, use 57250 (Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy) or 57260 (Combined anteroposterior colporrhaphy).

Caution: Code 45560, which is listed in CPT's Digestive System/Surgery section under Rectum, has only slightly more relative value units (RVUs) as the posterior colporrhaphy code 57250 (18.59 RVUs versus 18.03 RVUs). And while you might be tempted to use the higher-paying code, beware: If your physician has described performing a posterior colporrhaphy, even if he does not use that exact terminology, you must report 57250, Witt says.

How to tell: According to Witt, if the procedure is posterior colporrhaphy, the op report will describe the following elements: a midline incision of the posterior vaginal wall and perineum separation of the vaginal skin from the underlying fascia plication (folding and tacking down with sutures) of the rectovaginal fascia excision of any excess fascia, and plastic repair of the perineum involving suturing together the levator and perineal muscles when indicated.

The procedure described by 45560 can also start with a midline posterior wall incision, but the physician dissects the rectocele from the surrounding structures and plicates the rectum to the surrounding fascia. The physician follows with the excision of any excess vaginal mucosa and suturing together of the levator muscles. Normally a general surgeon performs this procedure to correct fecal incontinence.

Enterocele: To repair an enterocele, the ob/gyn will use either an abdominal or a vaginal approach. For the vaginal approach, report 57268 (Repair of enterocele, vaginal approach [separate procedure]), and for the abdominal approach, report 57270 (Repair of enterocele, abdominal approach [separate procedure]) under most circumstances. Because CPT labels these as "separate procedure," CCI bundles them into most other procedures. Check your individual payer rules before billing these codes.

Heads up: Sometimes the surgeon will describe a McCall culdoplasty as the method used to repair the enterocele. This procedure is actually an intra-peritoneal colpopexy (sometimes also referred to as a Mayo-McCall colpopexy) because the approach fixes the enterocele at the same time as it elevates the vaginal vault using the uterosacral ligament.