Ob-Gyn Coding Alert

Question: Gail A. Baxter, AAPC office manager for Douglas E. Heritage, MD (Woodbridge, VA) asks, When doing an endometrial biopsy on an older patient where a cervical dilation is performed what CPT codes should we bill? Weve been documenting the dilation on the chart and using the following codes: 99213 57; 58100 for endometrial biopsy; 57800 for dilation of the cervix. Why are we having trouble getting reimbursed?

Answer: There are a couple of issues here. The 57 modifier is intended for major surgery only. An endometrial biopsy done in the office along with an E/M service will need a 25 modifier attached to the E/M code 99213. You will want to make sure your documentation justifies the level of E/M coding. Concerning the biopsy and the dilation of the cervix, some insurance companies may try to bundle these together, but you can clarify this by linking each to different diagnosis codes. Link the biopsy to the diagnosis code appropriate for the procedure and then link the dilation to an appropriate diagnosis code such as cervical stenosis. Finally, attach the 51 modifier for multiple procedures to the 57800. Your coding should look like this:

99213 25

58100

57800-51

This, of course, is no guarantee the insurance company will pay as some carriers consider the dilation incidental to the biopsy, but it will probably give you a better chance at receiving adequate reimbursement.