Ob-Gyn Coding Alert

Plus, find out what to do when ob-gyns perform prophylactic salpingectomies.

When a patient no longer wishes to conceive children and requests a tubal ligation, you've got multiple coding options: a set of codes for procedures performed vaginally or via an open approach, a set of codes for laparoscopic procedures, and a code for Essure tubal ligations. So how should you choose the right code?

Key concept: You can sort through your tubal ligation choices if you zero in on three factors:

1) the ob-gyn's technique (laparoscope or hysteroscope versus open procedure),
2) transection (device or fulguration) method, and
3) delivery involvement.

Note:  You'll always report a tubal ligation with Z30.2 (Encounter for sterilization), no matter which type of tubal ligation the ob-gyn performs or the reason the patient (or patient's legal guardian) requested the tubal, says Melanie Witt, RN, MA, an ob-gyn coding expert based in Guadalupita, N.M.

Did MD Use a Laparoscope? Look to 2 Codes

If your ob-gyn uses a laparoscope, you will report either 58670 (Laparoscopy, surgical; with fulguration of oviducts [with or without transection]) if the tube is destroyed using electrocautery or laser or is cut in two and 58671 (... with occlusion of oviducts by device [eg, band, clip, or Falope ring]) if a device occludes the tube.

Look out: If an ob-gyn performs a "minilaparoscopic tubal," you will look to these two codes as well, Witt points out - but look at the technique to determine which code to use. These two codes differ based on technique regardless of whether the ob-gyn performs the ligation on its own or following a delivery.

Focus on 4 Options for Open/Vaginal Procedures

If your ob-gyn does not use a laparoscope and performs an open or vaginal procedure, you will report one of these four options:

• 58600 (Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral)
• 58605 (Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure))
• +58611 (Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (list separately in addition to code for primary procedure))
• 58615 (Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach).

Keep in mind:  Sometimes, physicians refer to a tubal procedure as a "Pomeroy tubal," Witt says. This technique involves tying a section of the tube, then removing it. Your ob-gyn can perform this via laparoscope (58670) or via an open procedure (58600, 58605, +58611). You will not report a salpingectomy code for this technique.

Do This When Ligation Follows Vaginal Delivery

You can report the tubal ligations following a vaginal delivery (59400, 59409-59410). If the tubal ligation occurs immediately after the delivery (during the same hospitalization as the delivery), use 58605. If the tubal ligation is performed at the same operative session as a vaginal delivery, you should append modifier 51 (Multiple procedures).

Good news: Because the tubal ligation requires a separate incision and is essentially unrelated to the vaginal delivery, carriers that pay for the ligation under other circumstances will generally not take issue with reimbursement using this coding sequence.

Keep in mind: If the tubal ligation occurs a day or more after the delivery (during the same hospital stay), use 58605 with modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period). You should receive full reimbursement for the procedure.

Cesarean Delivery with Ligation May Be a Battle

Cesarean delivery frequently offers the ob-gyn the chance to perform tubal ligation immediately after the delivery, sparing the patient an additional surgical session. You'll report +58611 in this case.

Red flag: Billing for tubal ligation at the time of cesarean is almost always a problem with payers because they count the cesarean incision as the incision for the ligation, Witt says. To these insurers, the ligation at the same session does not represent significant effort for the ob-gyn.

Although the American Congress of Obstetricians and Gynecologists (ACOG) specifically leaves tubal ligation off the list of bundled procedures in its policy on cesarean deliveries and global ob care with cesarean, some carriers will pay little or nothing extra for the procedure, Witt says.

Money saver: Tubal ligation performed at the time of cesarean delivery can prove a significant source of revenue, so practices should negotiate contract renewal to see that the procedure is reimbursed separately from the global package or cesarean delivery codes. "Also, you should point out to the payer that +58611 is an add-on procedure that does not take a modifier," Witt says. The Resource-Based Relative Value Scale (RBRVS) valued this code based solely on the intraoperative work.

Don't Overlook Essure Procedure

Your ob-gyn can also perform an Essure procedure, which involves implants into the fallopian tubes. For this procedure, you'll use 58565 (Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants).

Note: If the ob-gyn placed the device in only one tube (for instance, if the other tube was already blocked), you should add modifier 52 (Reduced services) to this code.

Plus, Here's How to Handle Prophylactic Salpingectomies

Caution: Many physicians are now performing a prophylactic salpingectomy in place of or in addition to the standard sterilization procedures. The American Congress of Obstetricians and Gynecologists (ACOG) published an article in August 2016 that discusses coding options when your ob-gyn performs this procedure.

In a nutshell, Witt says, you should always report the code for the sterilization and not a salpingectomy code, since this is valued based on work associated with a disease process. Should the physician insist on coding a salpingectomy, the diagnosis code must be reported as the prophylactic removal of an organ, such as Z40.09 (Encounter for prophylactic removal of other organ). Also, many payers will not reimburse for a prophylactic salpingectomy, so be sure that the patient is provided with informed consent for this procedure.