Ob-Gyn Coding Alert

Find out if your ob-gyn did a refitting at the time of a pessary insertion. If you think 57160 is all you need for pessary insertion procedures, think again. Not only will you have to consult your HCPCS and ICD-9 manuals, you must follow your practice's policy on whether the patient or you are responsible for the supplies. Pick Out Pertinent Pessary Dx A pessary is a "support device for pelvic-floor weakness, such as uterine prolapse, vaginal prolapse (enterocele, cystocele, rectocele), and stress urinary incontinence," says Cindy Foley, billing manager at three ob-gyn practices in Syracuse, N.Y. The pessary device is the most common—and occasionally the only—nonsurgical option for treating advanced uterine prolapse. Causes: Weakening of the muscles and ligaments that hold the uterus in place, which could be triggered by multiple vaginal deliveries, obesity, hormonal changes or old age, can cause the prolapse. Your most common ICD-9 codes to link to pessary devices are 618.0x (Prolapse of vaginal walls without mention of uterine prolapse), 618.1 (Uterine prolapse without mention of vaginal wall prolapse), or other 618.x, based on the degree of prolapse or when the patient has combined uterovaginal prolapse. Keep in mind: You need the information for the fifth digit of the diagnosis, "which is a necessity," Foley says. Make sure your ob-gyn provides the information in his notes. With the prolapse codes, the fifth digit gives you a different diagnosis for each ICD-9 code. For instance, 618.0 is not a valid code. All of the codes in the 618.0x category have a fifth digit that signifies the specific condition--for example, 618.00 (Unspecified prolapse of vaginal walls), 618.01 (Cystocele, midline) and so on. The two code categories under 618 that require a fifth digit are 618.0x and 618.8x (Other specified genital prolapse). Use 57160 Initially, E/M for Reinsertion CPT provides you with only one code for pessary insertion: 57160 (Fitting and insertion of pessary or other intravaginal support device). This code has no global days. Example 1: The patient presents with prolapse symptoms and the decision is made to insert the pessary during the same visit. You should report 57160 in addition to the exam code (such as 99211-99215). Remember to add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service. Keep in mind: However, Medicare includes the decision to do minor surgery with the performance of that procedure and states it is not appropriate to bill a separate E/M if this is the case. While Medicare may not know this at the time you submit the claim, they will note the global days assigned to 57170 which may lead to a review after the fact. Example 2: A Medicare patient is eligible for her screening pelvic and breast exam, and during this visit the ob-gyn inserts a pessary. You should report the pessary insertion 57160 in addition to G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination). Note that you do not add modifier 25 to G0101 because it is not an evaluation and management service. Red flag: If the patient returns for the cleaning and reinsertion of the pessary, you should report the E/M code for an established patient (99211-99215), depending on the examination and medical decision-making your ob-gyn documents in the chart. You would not include 57160. The E/M service includes the cleaning and reinsertion. The only way you could report 57160 again would be if the ob-gyn inserted a new pessary. "Sometimes the ob-gyn feels that he did a refitting at the time of the reinsertion and may feel justified to report 57160 again," Foley says. Rule: Unless the ob-gyn refits a new pessary, you can only bill an E/M service, never 57160. Best bet: "Find out if your ob-gyn is doing an initial fitting and insertion or a cleaning and reinsertion without a fitting," Foley says. "Show the CPT description of 57160 to your ob-gyn to help make the decision." Assess Your A4562 Strategy Medicare considers pessaries both a supply and prosthetic device. You should report them using the following HCPCS codes:

• A4561--Pessary, rubber, any type
• A4562--Pessary, non-rubber, any type.

Common: You're likely to use A4562 more than A4561. The reason is that A4562 represents silicone pessaries. Women fitted with silicone pessaries, rather than rubber ones, tend to have fewer allergic reactions to the material. Strategy 1: The problem with your practice providing the pessaries to patients is that the reimbursement for these devices may be much less than the manufacturers' price. For instance, in 2012, you can expect payment from $53 to a bit over $55 for a silicone Pessary under the Medicare payment schedule depending on your location. What you can do is have your ob-gyn provide the patient with a prescription to purchase the pessary directly from the supplier and then bring it to the office for the insertion (57160), experts say. Strategy 2: If your practice does provide the pessary to the patient, you should bill the insurance or Medicare for the device along with the pessary insertion (57160). Keep in mind: You would bill the pessary to the Part B carrier because Medicare considers pessaries supplies.