Ob-Gyn Coding Alert

CPT will offer new code in 2005 for permanent solution

Beginning April 1, you have a new tool in your arsenal for coding the Essure procedure, S2255. So you won't have to rely on the unlisted-procedure code.

The new HCPCS code, S2255 (Hysteroscopy, surgical; with occlusion of oviducts bilaterally by micro-inserts for permanent sterilization), presents a solution for many coders. Because some payers do not accept 58579 (Unlisted hysteroscopy procedure, uterus), coders were left with less accurate alternatives for reporting this procedure. Now, they have a specific code that directly addresses the surgery.

"This new code indicates some of the positive changes we will be seeing thanks to initiatives to respond more quickly to new technologies," says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

Generally, the Blue Cross/Blue Shield Association (BCBSA) and the Health Insurance Association of America (HIAA) use S codes to report drugs, services and supplies for which there are no national codes, according to the HCPCS manual. These are codes private payers need to implement policies, programs or claims processing.

Good news: CPT 2005 will include a permanent code for the Essure procedure, a reputable source who prefers to remain anonymous tells Ob-Gyn Coding Alert. This new CPT code will replace S2255 in January.

What Is Essure?

Ob-gyns use the Essure micro-insert as a new tubal ligation device. The surgeon uses a hysteroscope to place the insert into the proximal portion of each fallopian tube. When he releases the device, it expands and anchors in the fallopian tube where it will cause tissue to form around it that a few months later will block the tube. This results in sterilization. The ob-gyn can perform the procedure in the office under local anesthesia or conscious sedation, and it takes about 35 minutes to complete.

The patient must remain on birth control until the physician can perform a hysterosalpingogram (74740, Hysterosalpingography, radiological supervision and interpretation; and 58340, Catheterization and introduction of saline or contrast material for saline infusion sonohysterography [SIS] or hysterosalpingography) after three months to verify that the tubes are blocked.

How Does S2255 Help?

Before S2255, many coders were tempted to use 58615 (Occlusion of fallopian tube[s] by device [e.g., band, clip, Falope ring] vaginal or suprapubic approach) for the Essure procedure because the surgery involves occluding the fallopian tubes by a device through the vaginal canal, says Penny Schraufnagel, office manager for Ob-Gyn Center PA in Boise, Idaho. But CPT guidelines state that you should select a code that accurately identifies the service performed, not merely because it approximates the service provided.

Warning: CPT created 58615 to report a vaginal or suprapubic surgical approach to occluding the fallopian tubes. The Essure procedure, on the other hand, uses a hysteroscope to view the tubes to ensure that the ob-gyn can perform the procedure and then guide the insert's placement. The physician doesn't have to make a surgical incision. Consequently, because CPT didn't provide a code for the Essure procedure, you were left with the code for unlisted hysteroscopy procedures (58579) as the only correct coding solution.

"Use of unlisted codes is often necessary, but is time- consuming at best for getting paid," Callaway says.

For payers that didn't accept 58579, some coders reported 58615 along with 58555 (Hysteroscopy, diagnostic [separate procedure]) if the ob-gyn used the hysteroscope to determine whether he could perform the procedure, Schraufnagel notes. In this case, they would add modifier -59 (Distinct procedural service) to 58555.

If the physician used the hysteroscope simply to guide the device into place, however, the hysteroscopy was an integral part of the procedure and reporting it separately would have been inappropriate. But 58615 does not account for any additional work associated with the hysteroscopy. Consequently, coders would add modifier -22 (Unusual procedural services) to 58615. But this led to other payer questions regarding whether this was a truly unusual service.

Code S2255 wipes away these problems by providing one code that specifically describes the Essure procedure and those similar to it.

Watch Your Modifiers

Something to keep in mind when you're reporting S2255 is that its definition states it is a bilateral code. So regardless of whether your ob-gyn inserts the device in one fallopian tube or both, you can submit S2255 only once.

Watch out: In addition, you should not report S2255 with modifiers -50 (Bilateral procedure), -LT (Left side) or -RT (Right side) because these also denote that the code may be unilateral rather than bilateral.