Ob-Gyn Coding Alert

The National Correct Coding Initiative (NCCI) version 10.2 didn't stop with new mutually exclusive edits. You'll find scores of new nonmutually exclusive (NME) code bundles in the new version, so get ready to determine whether your claims warrant modifier -59 (Distinct procedural service) to separate the code combinations.

Nonmutually exclusive bundling edits pair codes for services included as part of more global (or comprehensive) procedures.

The majority of these types of edits permit you to use a modifier to bypass the bundle. But keep in mind that you must meet the criteria of modifier -59, says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver. Otherwise you cannot separate the services. In other words, you should use modifier -59 only for procedures or services that you would not normally report together, but are appropriate under the circumstances, such as when your ob-gyn performs a procedure during a different encounter, at a different site or organ system, or separate incision, among other reasons, according to CPT.

Cervical colposcopy codes 57455 (Colposcopy of the cervix including upper/adjacent vagina; with biopsy[s] of the cervix) and 57456 (... with endocervical curettage) now include 57410 (Pelvic exam under anesthesia) as a standard of medical and surgical practice. According to Medicare, standard of medical and surgical practice means "generic activities assumed to be included" and "integral to accomplishing a procedure."

Other new bundling edits that the NCCI added to this category include 57460 (Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy[s] of the cervix), which now bundles into 57400 (Dilation of vagina under anesthesia); and 57461 (Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix), which the NCCI now bundles into 57400.

NCCI 10.2 institutes dozens of edits based on a potential misuse of a Column 2 code with a Column 1 code. According to CMS, these edits do not involve "a comprehensive/component relationship" but "are codes that should simply not be reported together for other reasons, such as the misuse of the code."

For example, the NCCI now bundles 57420 (Colposcopy of the entire vagina, with cervix if present) into rectovaginal fistula closure code 57308 (Closure of rectovaginal fistula; transperineal approach, with perineal body reconstruction, with or without levator plication). And code 57308 includes 57452 (Colposcopy of the cervix including upper/adjacent vagina).

Also, you should note that the NCCI now bundles the myomectomy code 58145 (Myomectomy, excision of fibroid tumor[s] of uterus, 1 to 4 intramural myomas[s] with total weight of 250 grams or less and/or removal of surface myomas; vaginal approach) into codes 58950 (Resection of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy) and 58952 (... with radical dissection for debulking [i.e., radical excision or destruction, intra-abdominal or retroperitoneal tumors]).

If you try to report 58270 (Vaginal hysterectomy, for uterus 250 grams or less; with enterocele repair) separately from 58267 or 58291-58294 (Vaginal hysterectomy ...), you will need to separate them with a modifier and provide supporting medical documentation if the services are separate and distinct from one another. Look for numerous other hysterectomy codes that the NCCI now bundles into other hysterectomy codes. The chart below can help your practice easily reference the new Column 1/Column 2 bundles that affect ob-gyn coders.

NCCI 10.2 directs insurers to bundle codes 76941 (Ultrasound guidance for fetal transfusion), 76945 (Ultrasound guidance for chorionic villus sampling), and 76946 (Ultrasound guidance for amniocentesis) into new fetal surgery codes (59070-59076 and 59897). "Although Medicare has defined the bundles as a misuse of the Column 2 with the Column 1 code, the edit really reflects that the CPT definition specifically states these codes include ultrasound guidance," says Melanie Witt, RN, CPC, MA, an ob-gyn coding expert based in Fredericksburg, Va.

If you're reporting colposcopy procedures, you should take note of the new sequential procedures edits. By "sequential procedures," Medicare refers to procedures that a physician performs in direct succession to produce the same result. You should report these procedures using only the code of the procedure that the physician successfully accomplishes. You can use a modifier to separate these procedures if your documentation meets the criteria.

For example: When your documentation supports reporting 56821 (Colposcopy of the vulva; with biopsy[s]) separately from any of the vulvectomy codes (56620-56640), you should append modifier -59 (Distinct procedural service) to the bundled code (56821) to collect payment for both procedures.

The same rule applies when you report 57421 (Colposcopy of the entire vagina, with cervix if present; with biopsy[s]) separately from any of the vaginectomy codes (57106-57112), excision of vaginal cyst or tumor (57135), loop conization (57522), radical trachelectomy (57531), or any of the cervical stump excision procedures (57540-57556).

If you previously reported vaginal colposcopy with biopsy (57421) in addition to the dilation of the vagina (57400), insurers will pay 57400 but not 57421. NCCI 10.2 designates several extensive procedure edits for colposcopy and laparoscopic vaginal hysterectomy codes and cites the reason as "most extensive procedure edits."

According to Trailblazer (a Part B carrier in Texas), "when CPT descriptors designate several procedures of increasing complexity," you should submit "only the code describing the most extensive procedure actually performed."

For instance: You should not report 58553 (Laparo-scopic vaginal hysterectomy over 250 grams), in addition to the following codes unless the service meets the modifier criteria: