Ob-Gyn Coding Alert

(For a detailed description of colposcopies and why ob-gyns perform them, please see aarticle 6.)

"I think these codes are very helpful to let the carriers know more precisely the extent of work done with each particular colposcopy, therefore maybe increasing reimbursement," says Maureen Murphy, CPC, a coding specialist at Mount Kisco Medical Group in Mount Kisco, N.Y.

When reporting colposcopies of multiple sites, CPT states, you should code for each procedure, adding modifier -51 (Multiple procedures) as appropriate. For example, if the ob-gyn performs colposcopies of the vulva and vagina, bill for both 56820 and 57420, appending modifier -51 to the code with a lesser relative value. (CMS has not set relative values for these codes as of this printing. You can check for the new relative values when they are released at CMS' Web site: http://www.cms.gov.)

On the other hand, if the ob-gyn performs a superficial examination of the cervix with the colposcope, you should not report it separately from his or her examination of the entire vagina (57420 and 57421). Because the doctor's main interest when performing the procedure is the condition of the patient's vagina, his or her secondary look at the cervix is incidental. Similarly, if the physician uses the colposcope mainly to evaluate the cervix rather than the entire vagina, you should report only the cervical codes (57452-57461), says Jean Ryan-Niemackl, LPN, CPC, compliance analyst for QuadraMed, a multispecialty coding consulting firm in Fargo, N.D.

For example, the ob-gyn performs a colposcopy after a patient's Pap smear returns with abnormal results. He finds an area of abnormal tissue at the cervix and biopsies it. He then examines the rest of the vagina, but it looks normal. When reporting this procedure, you should bill 57455, Ryan-Niemackl says.

The descriptors for the new 2003 codes indicate that they include more than just the colposcopy of a particular anatomic site. For instance, 57452-57461 include not only colposcopy of the entire cervix but also an examination of the upper/adjacent portion of the vagina. You should use these codes both when the ob-gyn examines this area with the colposcope and when a cervical lesion extends into the vagina.

Similarly, current medical practice includes endocervical curettage as part of conization. Therefore, you may not report 57456 in addition to 57461.

CPT 2003 also revises 57460 and adds 57461 to clarify the two different cervical loop electrode excision procedures physicians might use with colposcopy. If the doctor uses the loop electrode to remove the exocervix and perhaps part of the transformation zone, if necessary, you should report 57460. If he or she performs conization that takes all of the exocervix, the transformation zone and some or all of the endocervix, use 57461.

To get a better picture of how you should use these codes, here are two coding examples:

Scenario 1: An ob-gyn performs a colposcopy of the vagina. He then uses the colposcope to take a biopsy of abnormal vulvar tissue.

You should report these procedures using 57420 for the vaginal colposcopy and 56821 for the vulvar biopsy, Ryan-Niemackl says. Append the lesser-valued code with modifier -51. If the physician uses the colposcope to examine the vulva, you would not report that separately because it is an incidental procedure the method the doctor uses to assist in performing the biopsy. Code 56821 includes examining the vulva with the colposcope and then performing a biopsy with or without the instrument's aid.

Scenario 2: A physician working in the emergency department (ED) examines a rape victim. He does an examination, reviews medical history and decides to perform a colposcopy to determine the extent of any damage to the patient's vagina and cervix.

In this case, you should report the colposcopy with 57420 because the physician looked at the entire vagina and the cervix was present. In addition, bill the appropriate ED E/M code (99281-99285, Emergency department visit for the evaluation and management of a patient ) to represent the doctor's work examining the patient and her history and making medical decisions about her diagnosis and treatment. You should append the E/M code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to show that it is separate from the colposcopy.