Ob-Gyn Coding Alert

Question: We would like to start using the Essure procedure, but how should we code this so our local carriers process the claims for payment?

Arizona Subscriber

Answer: The Essure is an instrument used to place a coil-like micro insert in the lower segment of the fallopian tubes. Tissue grows around the insert, creating a blockage in the tubes and causing sterilization. This is a relatively noninvasive and minor procedure. The ob-gyn inserts the device with the aid of a hysteroscope.

There are three options for reporting this service. First, you can report 58615 (Occlusion of fallopian tube[s] by device [e.g., band, clip, Falope ring] vaginal or suprapubic approach) and 58555 (Hysteroscopy, diagnostic [separate procedure]) appended with modifier -59 (Distinct procedural service) and possibly modifier -51 (Multiple procedures). This represents the most substantially correct method for coding the Essure procedure because it essentially involves occluding the oviducts via a vaginal approach, and CPT interprets that to mean by any method.

You should include the hysteroscopy because it is integral to the procedure but not included as part of 58615. Including modifier -59 is important because 58555 is a CPT separate procedure, and you would need modifier -51 because the hysteroscopy is a multiple procedure. If the ob-gyn provides the occlusion device, you should bill 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]). But if the surgeon performs the insertion in an inpatient hospital or outpatient surgical center, the facility normally will provide and bill for the supplies.

A second option is to report 58615 appended with modifier -22 (Unusual procedural services). This represents more simplified procedural coding, but it involves more physician documentation to effect payment. Using this modifier causes the carrier to manually review the claim, which can increase reimbursement time substantially. If your practice uses this method of performing a tubal as the standard procedure, a payer will quickly ignore the modifier -22 when you append it to every such service.

Finally, you can report the unlisted hysteroscopy code (58579). As with 58615-22, reporting the insertion with 58579 will require you to submit extensive documentation to explain the procedure to the carrier. And although you can suggest an appropriate payment amount, the insurance company will have the discretion to assign reimbursement as it sees fit.

The answers for Reader Questions and You Be the Coder were provided by Melanie Witt, RN, CPC, MA, an ob-gyn coding expert based in Fredericksburg, Va.