Ob-Gyn Coding Alert

If you’re reporting anything other than 58260-58294, prepare for a denial.

If your ob-gyns perform hysterectomies for UnitedHealthcare patients, then you need to understand this important coverage determination that will limit your ob-gyn’s approach.

Effective April 6, 2015, UnitedHealthcare, UnitedHealthcare West Commercial and their Medicare Plans will require prior authorization for abdominal and laparoscopic approach hysterectomies. This is being done, the company says, to align with the American Congress of Obstetricians and Gynecologists (ACOG)’s Committee Opinion #444, “Choosing the Route of Hysterectomy for Benign Disease,” released by the ACOG Committee on Gynecologic Practice in November 2009 (and reaffirmed in 2011).

This opinion indicates that “vaginal hysterectomy is the safest and most cost-effective method to remove the uterus for noncancerous reasons.” The opinion goes on to say that, “in general, based on the medical evidence, vaginal hysterectomy is associated with better outcomes and fewer complications than either laparoscopic or abdominal hysterectomy.” UnitedHealthcare states they are making this change because they are committed to provide better outcomes for their members.

If your ob-gyn performed a hysterectomy using a vaginal approach, you’ll pull a code from the 58260-58294 series.

What this Means to Gyn Practices

A vaginal hysterectomy done on an outpatient basis will not need prior authorization. But, according to the UnitedHealthcare January 2015 Network Bulletin “failure to complete the prior authorization process for all other approaches will result in an administrative claim denial, … and members cannot be billed for claims that are administratively denied.”

When you apply for authorization and it is determined during the clinical coverage review process that the approach does not meet the medical necessity criteria for doing an abdominal or laparoscopic approach, UnitedHealthcare will issue a clinical denial indicating the procedure is not medically necessary, and a prior authorization number will not be issued. Both the patient and the provider will receive a denial notice.

Non-covered codes: For a hysterectomy performed via the abdominal approach, these codes are 58150-58240. For a laparoscopic-assisted vaginal hysterectomy (LAVH), you’ll use 58550-58554. If your ob-gyn wants to perform a supracervical laparoscopic hysterectomy, you’ll report one of four codes: 58541-58544. And if your physician wants to perform a total laparoscopic hysterectomy, look to codes 58570-58573. According to UnitedHealthcare’s new policy, all of these codes will receive a denial.

If the patient, once they know that the approach has not been approved, decides to go ahead with the surgery anyway by agreeing in writing to be solely responsible for the costs of the surgery, the surgeon may perform the hysterectomy either abdominally or laparoscopically. However, no payment will be made by UnitedHealthcare, and the practice will need to collect payment from the patient.