Ob-Gyn Coding Alert

Question: We coded a vaginal hysterectomy with MMK as 58267 (vaginal hysterectomy; with colpo-urethrocystopexy [Marshall-Marchetti-Krantz type, Pereyra type, with or without endoscopic control]) and a 57240 (anterior colporrhaphy, repair of cystocele with or without repair of urethrocele) and received far less reimbursement than we anticipated. My doctor suggested that I break up the vaginal hysterectomy and the MMK procedure, but since there is a code for the combined procedure, I am afraid that we may get even less payment if they deny one of the two codes. I coded 58267-22 for vaginal hysterectomy with MMK procedure, with the modifier for unusual procedural services, and this is what he wants to bill out separately.

Bobby Meyers, Office Manager
Robert T. Byington, MD, Lincoln, Neb.

Answer: When coding procedures, you need to be aware of the rules that surround correct coding because payers are looking for errors that will allow them to take money back. This would be the least of your worries, however, as many payers are now prosecuting both the physician and the coder for deliberately unbundling procedures in an attempt to gain additional reimbursement.

A single code in CPT describes the performance of a vaginal hysterectomy and a Marshall-Marchetti-Krantz procedure. That code is 58267. A separate code, 57240, describes an anterior colporrhaphy. Correct coding in this instance would therefore be 58267 and 57240-51. Billing this procedure as you did using 58267-22 would be less correct because two separate codes already exist that describe all procedures performed on this patient. The insurance company normally would reduce payment for the second procedure by 50 percent of the allowable, because each surgical code includes some global services that would not be repeated for each procedure performed (that is, pre- and postoperative services).

In this case, however, I suspect that the insurance company paid only for the vaginal hysterectomy/MMK and denied the colporrhaphy because this procedure is being routinely bundled when a vaginal hysterectomy is performed. That does not mean you should not appeal such a denial. But if the physician performed the colporrhaphy as a prophylactic measure, rather than for the treatment of a cystocele or urethrocele, the insurance company likely will say that the physician had not established a medically necessary reason for performing the procedure. Check your EOB (explanation of benefits) message to find out what was paid, and the reason for any denial or fee reduction.

Source for Reader Questions is Melanie Witt, RN, CPC, MA, former program manager for the American College of Obstetricians and Gynecologists (ACOG) department of coding and nomenclature and an independent coding educator.