Ob-Gyn Coding Alert

Red flag: Your new codes aren't the only ones slammed with NCCI edits

You-ve got to get the full National Correct Coding Initiative version 13.0 picture and know how it affects your ob-gyn practice -- and now. You-ve got no grace period. Don't be daunted by thousands of edits. Our experts highlight what's most important.

New Supracervical Hysterectomy Codes Hit Hard

If you-re still rejoicing over the new laparoscopic supracervical hysterectomy codes CPT added for 2007, you may want to rethink your elation. NCCI 13.0 applies a slew of edits to these codes:

- 58541 -- Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less

- 58542 -- - with removal of tube(s) and/or ovary(s)

- 58543 -- Laparoscopy, surgical, supracervical hysterectomy, for uterus greater   than 250 g

- 58544 -- - with removal of tube(s) and/or ovary(s).

First, NCCI renders 58541-58544 -mutually exclusive- with vaginal and open supracervical codes including, but not limited to, 58152-58240, 58262-58294, and 58550-58554.

What that means: Mutually exclusive edits pair procedures that an ob-gyn would not reasonably perform at the same session, on the same anatomic location, or on the same beneficiary. If you were to report both these services, Medicare would pay only for the lesser valued of the two procedures.

Example: If you were to report both 58542 and 58270 (Vaginal hysterectomy, for uterus 250 grams or less; with repair of enterocele), you would receive payment only for the lesser-valued procedure -- in this case, 58270.

Keep in mind: When an edit pair has a modifier indicator status of -1,- you can separate it using a modifier (such as 59, Distinct procedural service) -- as long as you have supporting documentation. When the modifier indicator is -0,- you cannot separate the edit under any circumstances.

For these mutually exclusive edits, however, you can separate these edits with a modifier because they carry a status indicator of -1.-

Also, NCCI bundles 58541-58544 as mutually exclusive to the other approach codes for hysterectomy (58152-58294) and the laparoscopic-assisted vaginal hysterectomy (LAVH) codes (58550-58554). You can separate this edit if your ob-gyn started performing the hysterectomy with one approach, then converted to a different approach, says Melanie Witt, RN, CPC-OGS, MA, an ob-gyn coding expert based in Guadalupita, N.M. -But you should keep in mind that Medicare has a rule that if this is the case, you should only report the final approach surgery.-

Know These NME Hysterectomy Edits, Too

The edits for 58541-58544 are not limited to mutually exclusive pairs. You-ve got tons of comprehensive/ component edits to sort through as well.

-It's not surprising that these codes got hit with a bunch of edits,- but at least -most of them are common sense,- says Gloria Kirkham, CPC, coding specialist for Women's Health Partnership PC in Carmel, Ind. For example, you shouldn't code a diagnostic laparoscopy (49320, Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) with a laparoscopic supracervical hysterectomy because the hysterectomy codes can include the removal of tubes and/or ovaries, Kirkham says.

And CPT notes specify that you should not report 58541-58544 alongside 58140, abdominal approach myomectomy; 58150, total abdominal hysterectomy; 58661, laparoscopic removal of tube(s) and or ovary(s); or 58670-58671, laparoscopic tubal ligation procedures. The NCCI edits reflect these guidelines, but they are open to modifier use if you-ve got documentation. All of these edits carry a modifier indicator of -1.-

Heads up: Be careful trying to report the 58541-58544 codes with each other. NCCI bundles 58541 into 58542, while another edit bundles 58150 into 58544.

Don't Miss Other Hysterectomy Code Edit

You-ve got another new hysterectomy code for 2007 (58548, Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling [biopsy], with removal of tube[s] and ovary[s], if performed), and like the codes for laparoscopic supracervical hysterectomies, NCCI 13.0 slams 58548 with edits.
You should consider these procedures components of 58548: laparoscopic lymphadenectomy codes 38570-38572; diagnostic laparoscopy code 49320; radical vaginal hysterectomy 58285; laparoscopic supracervical hysterectomy codes 58541-58544; LAVH codes 58550-58554; BSO codes 58700-58720, 58940; and anesthesia injection codes 62318-62319, 64415-64417, 64450-64470 and 64475.

The modifier indicator for these edits is -1,- but that doesn't mean you can report a modifier like 59 whenever you simply want to get paid for both services. -It's important you remember that modifier 59 indicates the procedure or service was independent from the other services performed on the same day,- Kirkham adds. You-ve got to have documentation to back that up.

Narrow Down Nuchal Translucency Edits

Want to know more about how NCCI 13.0 will affect your coding? Check out this nuchal translucency news offered by Jackie Miller, RHIA, CPC, senior coding consultant for Coding Strategies Inc. in Powder Springs, Ga.

New code 76813 (Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation) is mutually exclusive with column 2 codes 76830 (Ultrasound, transvaginal) and 76857 (Ultrasound, pelvic [nonobstetric], real time with image documentation; limited or follow-up [e.g., for follicles]), which are for non-obstetrical studies.

Remember: Comprehensive/component edits describe bundled procedures. That is, CMS considers the code listed in column 2 as the lesser service, which is included as a component of the more extensive column 1 procedure.

And 76813 is a mutually exclusive column 2 code for two other non-obstetrical studies, 76831 (Saline infusion sonohysterography [SIS], including color flow Doppler, when performed) and 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete).
 
Get the Rest of the New Codes Story

Among the other NCCI edits applied to new codes, you should highlight these two new code edits.

Tumor debulking: If your ob-gyn performs surgery to remove cancer and repeats a surgery to debulk tumors, you-re probably elated to have new codes 58957 (Resection [tumor debulking] of recurrent ovarian, tubal, primary peritoneal, uterine malignancy [intra-abdominal, retroperitoneal tumors], with omentectomy, if performed) and 58958 (- with pelvic lymphadenectomy and limited para-aortic lymphadenectomy) among your coding options. But be careful. To 58957-58958, NCCI applies column 2 edits to reflect:

- CPT manual instructions (such as ovarian excision codes 58900-58951 and second-look procedure 58960) and

- standards of surgical medical practices (such as 90760-90775).

You can separate all of these edits if the documentation backs you up.

Graft revision: Check out the new edits affecting 57296 (Revision [including removal] of prosthetic vaginal graft; open abdominal approach). Components of 57296 include perineoplasty code 56810 and several vaginal and cervical surgery codes, plus 44005, 44180, 44820-44850, 44950, 49000-49010, 49255 and 51701-51703, but you can use a modifier with these codes to report them separately if this is supported by your ob-gyn's documentation.

Don't Forget the Old Codes

Finally, you-ll have to apply new edits to existing codes.

Your ob-gyn may need to use guidance when he must aspirate a cyst blindly through the skin or vaginal incision. That means if the ob-gyn uses ultrasound guidance to place the needle he uses to aspirate the cyst through the vaginal approach, you-ll report 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation). But don't report fluoroscopic guidance codes 77002-77003 or guidance codes 77031-77032. These procedures are mutually exclusive to 76942.

If you-re reporting partial hymenectomy code 56700 (Partial hymenectomy or revision of hymenal ring), you should keep in mind that NCCI bundles the newly renumbered code, 56442 (Hymenotomy, simple incision), into this procedure.

NCCI's list also includes edits for total abdominal hysterectomies (TAH). You-ll have to be extra cautious when adding codes for hernia repairs. NCCI bundles hernia codes 49560-49566 into 58150-58152 and 58200-58210. And NCCI bundles colectomy codes 44157-44158 into 58240 (Pelvic extent procedure).

You can't report column 2 code 57558 (Dilation and curettage of cervical stump) with column 1 code 58346 (Insertion of Heyman capsules for clinical brachytherapy) and expect to collect for both -- unless you use a documentation-supported modifier on 57558.

All of these regular code edits have modifier indicators of -1.-