Ob-Gyn Coding Alert

You can report mesh with some prolapse procedures -- learn which ones

If you-re concerned about when to report vaginal prolapse codes alone and when to report them together, help is here.
 
Our experts say that the keys to reporting prolapse codes properly are two things: the exact type of the prolapse and the ob-gyn's surgical approach.

Code Mesh With Colporrhaphy, Not Defect Repair

A patient may present to your office with a prolapse of the anterior vaginal wall, which is commonly called a cystocele (618.01, Prolapse of vaginal walls without mention of uterine prolapse; cystocele, midline; or 618.02, Prolapse of vaginal walls without mention of uterine prolapse; cystocele, lateral). Your physician will perform either an anterior colporrhaphy or a paravaginal defect repair, so you-ll have to choose between two procedure codes.
 
For an anterior colporrhaphy, use 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele). If the ob-gyn also repairs a urethrocele (618.03), you should not separately report its repair because it is included in the code description of 57240.
 
Bonus: During some anterior colporrhaphy procedures, the surgeon will add mesh to strengthen the repair, says Melanie Witt, RN, CPC-OGS, MA, an independent coding consultant in Guadalupita, N.M. You should report the mesh insertion using +57267 (Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site [anterior, posterior compartment], vaginal approach [list separately in addition to code for primary procedure]). This add-on code requires no modifier or fee reduction and has an unadjusted 2006 Medicare allowable of $284.23.
 
When the surgeon performs a paravaginal defect repair via an open or vaginal approach, report 57284 (Paravaginal defect repair [including repair of cystocele, stress urinary incontinence, and/or incomplete vaginal prolapse]). For a laparoscopic approach, use 49329 (Unlisted laparoscopy procedure, abdomen, peritoneum and omentum), Witt says.
 
Beware: The National Correct Coding Initiative bundles the Burch procedure, slings, anterior colporrhaphy and enterocele repair with the paravaginal defect repair, so you cannot report them separately. You also can't report 57267 for a mesh insertion with 57284 or 49329 even though it is not an NCCI bundle, Witt says. -This is because CPT specifically cites the codes that can be billed with an add-on mesh, and CMS does not normally create bundles for code combinations that are clearly spelled out in CPT,- she adds.
 
Tip: When your ob-gyn adds a mesh to a paravaginal defect repair, append modifier 22 (Unusual procedural services) to 57284 to indicate the extra work involved. Submit a detailed op report as well as a concise explanatory note of the procedure in layman's terms.

You Have 4 Choices for Vaginal Prolapse Treatment

If a patient has a prolapse of either the uterus or the vaginal vault, your physician will most likely perform a vaginal vault suspension, called a colpopexy. How the surgeon approaches the problem and where he anchors the suspending sutures determine which code you should use to report the procedure.
 
If the ob-gyn uses an abdominal approach and attaches the vaginal vault to the sacrum, you should report the colpopexy with 57280 (Colpopexy, abdominal approach), says Nina Mutone, MD, medical director of the urogynecology division at St. Vincent's Hospital in Indianapolis. If the physician uses a transvaginal approach, you should report 57282 (Colpopexy, vaginal; extra-peritoneal approach [sacrospinous, iliococcygeus]).
 
A third type of vaginal vault suspension involves an intraperitoneal vaginal approach. For this procedure, you would use 57283 (Colpopexy, vaginal; intra-peritoneal approach [uterosacral, levator myorrhaphy]).
 
Another option: If your ob-gyn incorporates a laparoscopic approach, you-ll use yet another code, Witt says: 57425 (Laparoscopy, surgical, colpopexy [suspension of vaginal apex]).
 
Caution: Don't report the addition of mesh using 57267 with the colpopexy codes because you can only use 57267 as an add-on code with 45560 (Repair of rectocele [separate procedure]), 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele), 57250 (Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy), 57260 (Combined anteroposterior colporrhaphy), and 57265 (... with enterocele repair).

Look at Approach for Rectocele Repair Coding

Two other prolapse problems your physician might repair are rectocele (618.04, Prolapse of vaginal walls without mention of uterine prolapse; rectocele) and enterocele (618.6, Vaginal enterocele, congenital or acquired), and each has its own procedure code options.
 
-A rectocele repair is the repair of a prolapse of the back wall of the vagina between the vagina and the rectum,- Mutone says. For this procedure, report 45560 (Repair of rectocele [separate procedure]) if the physician doesn't repair the rectocele by performing a posterior colporrhaphy. If he performs the repair with a posterior colporrhaphy, use 57250 (Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy) or 57260 (Combined anteroposterior colporrhaphy).
 
Caution: Code 45560, which is listed in the Digestive System/Surgery section of CPT under the heading of -Rectum,- has more than twice the number of relative value units as the posterior colporrhaphy code 57250. You might be tempted to use the higher- paying code, but beware: If your physician has described performing a posterior colporrhaphy, even if he does not use that exact terminology, you must report 57250, Witt says. 
 
How to tell: According to Witt, if the procedure is posterior colporrhaphy, the op report will describe the following elements:
 
- a midline incision of the posterior vaginal wall and perineum,
 
- separation of the vaginal skin from the underlying fascia,
 
- plication (folding and tacking down with sutures) of the rectovaginal fascia,
 
- excision of any excess fascia, and
 
- plastic repair of the perineum involving suturing together the levator and perineal muscles when indicated.

Note: The procedure described by 45560 can also start with a midline posterior wall incision, but the physician dissects the rectocele from the surrounding structures and plicates the rectum to the surrounding fascia. The physician follows with the excision of any excess vaginal mucosa and suturing together of the levator muscles.
 
To repair an enterocele, the surgeon will use either an abdominal or a vaginal approach. For the vaginal approach, report 57268 (Repair of enterocele, vaginal approach [separate procedure]), and for the abdominal approach report 57270 (Repair of enterocele, abdominal approach [separate procedure]).
 
Because CPT labels these as -separate procedure,- NCCI bundles them into most other procedures. Check your individual payer rules before billing these codes.