Ob-Gyn Coding Alert

Meeting the multifaceted needs of women patients, the ob/gyn often performs more than one service or procedure on the same day, or during the same global surgical period. Unfortunately, reporting extra activity cannot be accomplished by simply stacking the procedure and service codes or submitting a bill that ignores additional activity. The services and procedures have to be reported with the help of modifiers. The most commonly used (and perhaps most misunderstood) modifiers to report these circumstances are modifiers -51, -58, -59 and -79.

Theres still a lot of confusion around these modifiers, says Becky Dawson, CPC, compliance education specialist for the Department of Surgery Corporation of Columbus, OH.

Modifier 51: Multiple Procedures

This modifier is used for multiple procedures performed on the same day or at the same session by the same provider. For example, if the physician performs a vaginal hysterectomy, and during that same session performs an anterior and posterior colporrhaphy, this qualifies as multiple procedures and may be reported using the -51 modifier.

The 1999 CPT clarifies the use of this modifier by saying that in using -51, coders must report the most significant procedure first, with all other procedures listed with the -51 modifier appended. Therefore, report the vaginal hysterectomy (58260) first without the modifier and then the combined anteroposterior colporrhaphy (57260) with the -51 modifier.

There are codes with which you should not use the -51 modifier, such as add on codes and assorted other. The -51 modifier also is not meant to be used with Evaluation and Management Services. But the new 1999 CPT makes this exclusion easier to understand by identifying the add-on codes with a big + symbol, and other codes excluded from -51 modifier use with the W symbol. In addition, all of these codes excluded from the -51 modifier are listed in CPTs Appendices E and F.

According to Dawson, the -51 modifier receives mixed acceptance from payers. Some carriers are asking that it not be used, she says. If you are experiencing denials, check with your payers.

Modifier -58: Staged or Related Procedures

A common situation in ob/gyn practices that signals the need for modifier -58, Dawson says, is when a lump or growth is biopsied and then the patient goes back for more surgery during the same global period. Offering some clarification, the 1999 CPT states that the -58 modifier is used when a procedure(s) is prospectively planned as a staged procedure, or when the secondary and subsequent procedure(s) is more extensive, or to indicate therapy following a diagnostic surgical procedure In other words, modifier -58 should be used if a procedure, performed by the same physician during the postoperative period, is:

A) Planned prospectively at the time of the original procedure (staged). There are several planned, related parts to the patients treatment. For example, a physician examines a patient with postmenopausal bleeding and a family history of ovarian cancer. A staged work-up and treatment is planned. A dilation and curettage (58120) is performed with a specimen sent for analysis. The pathology report reveals an endometrial carcinoma. The following day, a radical TAH/BSO and bilateral pelvic lymphadenectomy (58210) is performed. These services are reported using 58120 and 58210-58. Because the two procedures were not performed at the same surgical session, the procedure code 58120 is listed first and takes no modifier.

B) More extensive than the original procedure. A more extensive but related procedure is performed during the postoperative period. For example, a patient with a complaint of infertility is examined and a diagnostic laparoscopy (56300) is performed revealing that the fallopian tubes are narrowed. After discussing the options with the patient, a transcervical introduction of fallopian tube catheter to re-establish patency (58345) is performed. If billed on the same claim form, the two procedures would be billed as 58345-58 and 56300.

Although the diagnostic laparoscopy is a CPT separate procedure, a modifier on code 56300 would not be needed in this case because the procedures were performed on different days. The highest valued procedure, the transcervical introduction of fallopian tube catheter, 58345, is listed first on the claim. If the transcervical procedure is billed on a separate claim form, report it as 58345-58.

C) For therapy following a diagnostic surgical procedure. A diagnostic procedure is followed by related therapy. For example, an endocervical curettage (57505) is performed revealing trichomonal vulvovaginitis. The following day, the vagina is irrigated with the application of medicament (57150). The procedure and related therapy are reported, with codes 57505 and 57150-58.

The -58 modifier is not to be used when there is a return to the operating room for a problem that arises from the original procedure. For example, if following a TAH , the patient is found to be bleeding internally and must return to the operating room, this is reported using modifier -78, return to the operating room for a related procedure during the postoperative period.

Modifier -59: Distinct Procedural Service

According to Dawson this modifier should be used only when no other modifier applies to services performed by the same physician on the same day.

The modifier -59 may sometimes be used with the primary procedure if that procedure has the highest RVU. Modifier -59 will most frequently be added to a code that is a CPT separate procedure performed for a reason unrelated to the primary procedure.

But as the 1999 CPT states, this modifier is appropriate under certain circumstances. These include:

A) A different session or patient encounter. The distinct service is in a different patient encounter (even though the same procedure may be repeated). For example, a fetal non-stress test is performed on a pregnant patient in the morning. That afternoon, the patient trips on her front steps and falls. She returns to the physicians office to make sure her baby is fine and a second fetal non-stress test is performed. Both of the tests are reported with 59025 plus 59025-59.

B) A different procedure or surgery. For example, a total abdominal hysterectomy (58150) for uterine fibroids is performed along with the repair of a large enterocele (57270). The enterocele repair is a separate procedure, but because it is a different procedure, it may be billed with a modifier -59. Both procedures are reported as 58150, plus 57270-59.

C) A different anatomical site or organ system. This makes the procedural services distinct. For example, an endometrial biopsy (58100, separate procedure) is performed and at the same surgical session a breast cyst aspiration (19000) is performed. Both procedures are reported as 58100-59 plus 19000. The highest valued procedure is listed first on the claim form.

D) A separate incision/excision. In this section, the second procedure is distinct because it is a separate incision/excision. For example, a marsupialization of a Bartholins gland cyst (56440) and an excision of a lesion on the labia majora (56501) are performed during the same surgical session. Both procedures are reported as 56440, plus 56501-59.

E) A separate lesion. For example, drainage of an ovarian abscess (58820) is performed on a patients right ovary and, at the same operative session, on the left ovary, a cyst (58800, separate procedure) is drained. Both procedures are reported as 58820, plus 58800-59.

F) A separate injury. An injury occurs during a procedure, requiring another procedure. For example, a cesarean delivery is complicated by an inadvertent cystotomy. The same physician then performs a cystorrhaphy (51860). The procedures are reported with codes 59510 (assuming global ob care), plus 51860-59. In this situation, its important to note that Medicare will not reimburse the primary physician for an inadvertent injury.

Modifier -79: Unrelated Procedures or Service

During the postoperative period, a procedure may be required that is totally unrelated to the original surgery. So that full reimbursement can be obtained, The 79 modifier should stop the payer from considering the new procedure part of the original period, says Dawson. For example, a laser conization of the cervix (57520) is performed and has a 90-day post-global period. Six weeks after the procedure, some vulvar lesions are destroyed (56501). The vulvar lesion procedure is unrelated to the conization of the cervix and is reported with code 56501-79.