Ob-Gyn Coding Alert

Over-applying modifier 52 may mean you're cutting out ethical reimbursement your physician deserves, and in these tough economic times, that's the last thing you want to do.

A subscriber wrote to the editor regarding "3 Details Narrow Down Your Tubal Ligation Coding Options" featured in the Ob-gyn Coding Alert 2010 Volume 13, No.1. The article states, "when the ob-gyn ligates only one tube or places the device on only one tube, CPT indicates that you should add modifier 52 (Reduced services) to the code."

This advice would be correct for codes that specify "bilateral" but not for codes specifying "unilateral or bilateral," points out Donna Cuifolo, CCS-P, coding/compliance coordinator at Jamestown Area Medical Associates in N.Y. "Coders need to understand this difference because adding modifier 52 when it is not necessary will inappropriately reduce the payment to the physician," Cuifolo emphasizes.

For example, take a look at codes 58600 (Ligation or transection of fallopian tube[s], abdominal or vaginal approach, unilateral or bilateral) and 58605 (Ligation or transaction of fallopian tube[s], abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization [separate procedure]). Because these code descriptors state "unilateral or bilateral," you would not add modifier 52 if the ob-gyn only ligates one tube. The "unilateral" takes care of that.

Along the same lines, you might also argue that code 58615 (Occlusion of fallopian tube[s] by device [e.g., band, clip, Falope ring] vaginal or suprapubic approach) might represent a unilateral or bilateral procedure since the description includes "tube(s)" rather than "tubes."

Watch out: The 2010 Medicare Physician Fee Schedule clearly indicates that you should consider every tubal procedure inherently bilateral -- and many payers agree. Additionally, CPT considers laparoscopic and hysteroscopic approaches for tubal occlusion or fulguration to be bilateral. In other words, codes 58670-58671 (Laparoscopy, surgical; with fulguration of oviducts [with or without transection] ...) read "oviducts." Similarly, 58565's definition states, "Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants." This means if the obgyn performs only one implantation or fulgurates only one fallopian tube using a scope, then you should add modifier 52 to show a reduced service.

Editor's Note: Thanks to Ms. Cuifolo for shedding light on this important distinction. Do you have a clarification or success story to share? Email the editor at suzannel@inhealthcare.com.