Ob-Gyn Coding Alert

Question: I am wondering if you can help me in finding official resources on coding culdoplasty and/or colpopexy with hysterectomy? 

I had coded a chart where a patient had a laparoscopic assisted vaginal hysterectomy (LAVH) and McCall’s culdoplasty. As the patient did not have an enterocele, I coded 58554 for the hysterectomy. The ob-gyn did the culdoplasty as a preventative measure to prevent prolapse in the future. 

The chart was audited, and I was asked to code the culdoplasty separately. When I disagreed with the finding, I am now being asked to code a colpopexy, using code 57283, as the auditors feel that “something must be coded.” 

I still disagree, as I feel that coding a preventative measure is not ethical, and I have been given no diagnosis to support a colpopexy. 

I had enclosed articles by Melanie Witt, published by the Coding Institute, but unless I have something “official”, the auditors are unwilling to accept these. I have scoured the Internet trying to find official word from Medicare on this. Do you have any suggestions where this could be found?

Codify Subscriber

Answer:  You should be contacting the American Congress of Obstetricians and Gynecologists (ACOG) with this issue if you need clinical/coding proof. 

However, affixing the uterosacral/cardinal complex to the cuff and closing the peritoneum (some omit that part) is all part of a garden-variety, standard vaginal hysterectomy as described in each and every surgical text on this topic. The closure part is bundled in, and quite frankly, a provider should never NOT do it.  

Now, if a diagnosis of enterocele were mentioned, and considerable additional time, work, and risk were incurred with the McCall’s colpopexy, you can reasonably bill the repair separately. But the cuff closure with these additional sutures with a routine vaginal hysterectomy is like putting the peritoneum back together after a TAH: it’s part and parcel of the major procedure.

If you expect payment for the McCall, you will need to indicate a separate diagnosis for it, and it needs to be documented in the record. The physician must either document the presence of an enterocele needing to be fixed or the presence of significant vaginal vault prolapse still present after he took the uterus out (not prolapse before surgery, which should be addressed via taking the uterus out with the few stitches done to close the vaginal cuff). 

The McCall culdoplasty can be billed using the same code as an intraperitoneal colpopexy (57283, Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy) since the work involved is similar. Keep in mind the policy of most payers centers on the basic principle restoring normal function. When there is no enterocele, normal functioning is not restored; and unless the payer specifically reimburses for prophylactic/preventive surgical procedures, you should not bill for it.