Ob-Gyn Coding Alert

The 1999 CPT books have hit the streets,and its time to figure out what applies to the ob/gyn coder.

General Layout and Symbols

Thumbing through the new CPT, you wont notice any huge changes from the 1998 book except for a couple of new symbols and new appendices. The layout is generally the same. There is one notable exception. In the Evaluations and Management (E/M) Guidelines and the Surgery Guidelines sections of the 1998 CPT, a complete list of modifiers for that section appears with full descriptions. In the 1999 CPT, the E/M Guidelines include no modifier descriptions, and the Surgical Guidelines only list seven modifiers with abbreviated descriptions under a section entitled Reporting More than One Procedure/Service. Instead, detailed descriptions for all modifiers appear only in Appendix A.

Because it is the codes themselves that capture revenues, you will want to be aware of additions, revisions and deletions in each section. As in the past, new codes are indicated with the large fat dot l before the code number. Codes with substantial revision have a s in front of the code number, and the symbols appear on either side of new and revised notes. All of the new, revised and deleted codes are listed in Appendix B, which includes 676 changes for 1999. The following highlights the changes most noteworthy to ob/gyn coders, along with notes and comments about these changes from ACOGs Department of Coding and Nomenclature.


E/M Services Guidelines

Attempting to clarify the confusion around the reporting of both an E/M service and a procedure on the same day, the CPT has added two new paragraphs in the section under Levels of E/M Services (CPT 1999, page 3). ACOG comments that, Specifically, CPT has clarified that when the patients condition requires a significant, separately identifiable E/M service that is above and beyond the usual pre-service and post-service care associated with a procedure that was performed at that encounter, both the E/M service (with a modifier -25 added) and the procedure may be reported. The new CPT paragraphs state that different diagnoses are not required for each service as the E/M service may be caused or prompted by the symptoms or conditions for which the procedure and/or service was provided. ACOG poses this example: a patient presents with vaginal bleeding, and following an evaluation of the problem, the physician decides to perform an endometrial biopsy at the same encounter.

Tip: This does not change the rules surrounding reporting CPT starred procedures where an E/M service for an established patient would not be reported in addition to the procedure if that procedure constituted the major service at the encounter.

Preventive Medicine Service Guides

Addressing the question of whether an Office/Outpatient Code can be reported at the same time as a Preventive Medicine Service code, the CPT has added a sentence in the introductory paragraph to the Preventive Medicine Section of E/M Services that says the appropriate preventive medicine service is reported in addition to the Office/Outpatient Code. In the example of a patient who comes in for a well-woman exam but also complains of a stomach pains and dizziness, ACOG says, The physician performs the comprehensive history and examination and then documents the additional work involved in evaluating the presenting problems. Both the preventive service and the E/M office/outpatient service may be reported. A modifier -25 would be added to the code representing the problem E/M service.

Many OCA readers will be happy that CPT has finally clarified that indeed, the comprehensive examination required for the Preventive Services codes is NOT synonymous with the comprehensive examination required in Evaluation and Management codes 99201-99350.

Surgery Guidelines

1. Add-on Codes.

CPT has provided additional identification of add-on codes. These are procedures commonly carried out at the same time and in addition to the primary procedure performed. According to ACOG, an example would be a biopsy of two vulvar lesions where the first lesion is reported using CPT code 56605 and the additional lesion by reporting CPT code 56606. Using the [ symbol, the CPT now indicates before the code which codes are designated as being add-on codes. All add-on codes are now listed in the new Appendix E. New wording clarifies that the CPT add-on code concept applies only to add-on procedures/services performed by the same physician. Additional wording points out that all add-on codes are exempt from the multiple procedure concept, and therefore do not take a modifier 51 because they can only be reported with a primary procedure. CPT has also added the symbol W which will appear before the code to indicate procedures or services that are not defined as add-on codes but which are also exempt from modifier 51. All of these codes are listed in Appendix F.

2. Modifiers.

As already mentioned, the new edition of the CPT includes only seven modifiers with abbreviated descriptions in the surgery guidelines (-51, -58, -59, -76, -77, -78, -79). ACOG points out that this does not mean that these are the only modifiers that can be used with surgery codes. Additional modifiers that can be used are -22, -26, -47, -50, -52, -53, -54, -55, -56, -57, -62, -80. The complete list of modifiers with full descriptions is located in Appendix A.

In addition to listing modifiers, Appendix A includes a listing of modifiers approved for ambulatory surgery centers (ASC) and hospital-outpatient use, divided into two levels. Level I CPT modifiers include modifiers for bilateral procedures, reduced services, distinct procedural service and repeat procedures. Level II modifiers are used only by the Medicare program (e.g., -LT, -RT). There are two new modifiers for Level I:

Modifier -73 - (Discontinued outpatient hospital/ambulatory surgery center procedure prior to the administration of anesthesia): ACOG states, This modifier is reported by the ASC or outpatient hospital when the physician cancels a surgical or diagnostic procedure after surgical preparation, but before anesthesia induction because of extenuating circumstances or those that threaten the well being of the patient. A modifier -53, on the other hand, would be reported by the physician (as opposed to the facility) when a procedure is discontinued after surgical preparation and/or anesthesia induction.

Modifier -74 - (Discontinued outpatient hospital/ambulatory surgery center procedure after administration of anesthesia): ACOG states, This modifier is reported by the ASC or outpatient hospital when the physician cancels a surgical or diagnostic procedure after anesthesia induction or after the procedure was begun because of extenuating circumstances or those that threaten the well being of the patient. As above, modifier -53, rather than modifier -74 would be reported by the physician when a procedure is discontinued after surgical preparation and/or anesthesia induction.

Female Genital System

Codes for colpectomy have been revised and expanded to include radical vaginectomy with and without bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling. There are five new codes (57106, 56107, 57109, 57111 and 57112), and code 57110 has been revised. The partial colpectomy code (57108) has been deleted. Codes 56606 (biopsy of an additional vulvar or perineal lesion) and 58611 (tubal ligation at the time of cesarean delivery) have been designated as CPT add-on codes. A sentence has been added to the nomenclature for each code to indicate that the add-on code would be listed in addition to the code for the primary procedure.

Maternity Care and Delivery

Code 59525 (subtotal or total hysterectomy after cesarean delivery) has been designated as a CPT add-on code and a sentence has been added to the nomenclature for each code to indicate that the add-on code would be listed in addition to the code for the primary procedure.

Radiologic and Laboratory Services

In Radiologic Services, a new code has been added: 76977 for reporting ultrasound bone density measurement. ACOG notes, that code, however, would not be reported if this procedure was performed on a Medicare patient. Instead, Medicare requires that this procedure be billed using their new HCPCS alphanumeric code, G0133.

In Laboratory Services, among other changes, a new code, 82731, has been added to measure fetal fibronectin in cervicovaginal secretions. ACOG says, We are still checking to see if this code qualifies as a CLIA waived test or whether it will be considered a complex test that cannot be performed by the obstetrician without a CLIA certificate for that level of test.

One of the biggest changes in Laboratory Services applicable to ob/gyns is a total revamping of the cytopathology codes dealing with cervical or vaginal screening by various methods. Twelve new codes (88143-88148, 88153-88154, and 88164-88167) have been added to report samples collected in preservative fluid, screening by automated system, and manual screening by a physician using the Bethesda system. Three codes (88142, 88150, 88152) were revised to make them fit better within the new structure, and two codes (88141, 88155) have been designated as CPT add-on codes.

Notable Additions and Revisions for Ob-Gyn

Below is a list of codes that ACOG had designated as being pertinent additions and revisions for codes that may impact obstetricians and gynecologists in the AMAs CPT 1999. As always, please consult the 1999 CPT for a complete listing and complete descriptions of the changes.

1. Add-on Codes.

19001 - Puncture aspiration of cyst of breast; each additional cyst (List separately in addition to code for primary procedure)

19126 - Excision of breast lesion identified by preoperative placement of radiological marker; each additional lesion separately identified by a radiological marker (List separately in addition to code for primary procedure)

56606 - Biopsy of vulva or perineum (separate procedure); each separate additional lesion (List separately in addition to code for primary procedure)

58611 - Ligation or transection of fallopian tube(s) when done at the time of cesarean section or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure)

59525 - Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure)

88141 - Cytopathology, cervical or vaginal (any reporting system); requiring interpretation by physician (List separately in addition to code for technical service)

88155 - Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (eg, maturation index, karyopyknotic index, estrogenic index) (List separately in addition to code(s) for other technical and interpretation services)

90781 - IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; each additional hour, up to eight (8) hours (List separately in addition to code for primary procedure)

96412 - Chemotherapy administration, intravenous; infusion technique, one to 8 hours, each additional hour (List separately in addition to code for primary procedure)

96423 - Chemotherapy administration, intra-arterial; infusion technique, one to 8 hours, each additional hour (List separately in addition to code for primary procedure)

2. Codes not requiring a modifier -51.

99141 - Sedation with or without analgesia (conscious sedation); intravenous, intramuscular or inhalation

99142 - oral, rectal and/or intranasal

3. Female Genital System Codes.

57106 - Vaginectomy, partial removal of vaginal wall;

57107 - with removal of paravaginal tissue (radical vaginectomy)

57109 - with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy)

57110 - Vaginectomy, complete removal of
vaginal wall;

57111 - with removal of paravaginal tissue radical vaginectomy)

57112 - with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy)

4. Radiological Codes.

76977 - Ultrasound bone density measurement and interpretation, peripheral site(s), any method

5. Laboratory Codes.

80054 - Comprehensive metabolic panel (includes albumin, total bilirubin, calcium, carbon dioxide, chloride, creatinine, glucose, alkaline phosphatase, potassium, total protein, sodium, AST SGOT, and BUN)

80058 - Hepatic function panel (includes albumin, total and direct bilirubin, alkaline phosphatase, SGPT and SGOT)

82247 - Bilirubin; total

82248 - direct

82731- Fetal fibronectin, cervicovaginal secretions, semi-quantitative

88142 - Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision

88143 - with manual screening and rescreening under physician supervision

88144 - with manual screening and computer-assisted rescreening under physician supervision

88145 - with manual screening and computer-assisted rescreening using cell selection and review under physician supervision

88147 - Cytopathology, smears, cervical or vaginal; screening by automated system under physician supervision

88148 - screening by automated system with manual rescreening

88150 - Cytopathology, slides, cervical or vaginal; manual screening under physician supervision

88152 - with manual screening and computer-assisted rescreening under physician supervision

88153 - with manual screening and rescreening under physician supervision

88154 - with manual screening and computer-assisted rescreening using cell selection and review under physician supervision

88164 - Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision

88165 - with manual screening and rescreening under physician supervision

88166 - with manual screening and computer-assisted rescreening under physician supervision

88167 - with manual screening and computer-assisted rescreening using cell selection and review under physician supervision

89264 - Sperm identification from testis tissue, fresh or cryopreserved

6. Medicine Codes.

90281 - Immune globulin (IG), human, for
intramuscular use

90371 - Hepatitis B immune globulin (HBIG), human, for intramuscular use

90384 - Rho(D) immune globulin (RhIG), human, full-dose, for intramuscular use

90385 - Rho(D) immune globulin (RhIG), human, mini-dose, for intramuscular use

90386 - Rho(D) immune globulin (RhIGIV), human, for intravenous use

90396 - Varicella-zoster immune globulin, human, for intramuscular use

90471 - Immunization administration (includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections and/or intranasal or oral administration); single or combination vaccine/toxoid

90472 - two or more single or combination
vaccines/toxoids

90658 - Influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use

90659 - Influenza virus vaccine, whole virus, for intramuscular or jet injection use

90660 - Influenza virus vaccine, live, for intranasal use

90669 - Pneumococcal conjugate vaccine, polyvalent, for intramuscular use

90710 - Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use

90718 - Tetanus and diphtheria toxoids (Td) absorbed for adult use, for intramuscular or jet injection

90732 - Pneumococcal polysaccharide vaccine, 23-valent, adult dosage, for subcutaneous or intramuscular use

90744 - Hepatitis B vaccine, pediatric or pediatric/adolescent dosage, for intramuscular use

90745 - Hepatitis B vaccine, adolescent/high risk infant dosage, for intramuscular use

90746 - Hepatitis B vaccine, adult dosage, for intramuscular use

90747 - Hepatitis B vaccine, dialysis or immunosuppressed patient dosage, for intramuscular use

90748 - Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use