Ob-Gyn Coding Alert

Find out where you should look for your prolapse diagnosis codes in ICD-10.

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/ICD-10 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. 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 uterine prolapse), 618.1 (Uterine prolapse without vaginal wall prolapse), or other 618.x, based on the degree of prolapse or whether the patient has combined uterovaginal prolapse.

Keep in mind: You need the information for the fifth digit of the diagnosis for vaginal wall prolapse, which is a necessity, experts say. Make sure your ob-gyn provides the information in his notes.

With the vaginal 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).

ICD-10: When your diagnosis coding system changes, you will switch to the N81.-- (Female genital prolapse) category. For instance, a midline cystocele will be N81.11 (Cystocele, midline).

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 for her yearly examination, and the ob-gyn decides to fit her with and insert a pessary during the same visit. You should still report 57160 in addition to the exam code (such as 99211-99215 or 99395-99397). Remember to add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M or preventive service.

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).

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 cleaning and reinsertion is included in the E/M.

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, experts say. 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. 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 an orthotic. 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, experts say. 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 is much less than the manufacturers’ price. 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.