Ob-Gyn Coding Alert

You can sort through your tubal ligation choices if you zero in on the ob-gyn's technique (laparoscope or hysteroscope versus open procedure), transaction (device or fulguration) method, and delivery involvement.

When a patient no longer wishes to conceive children and requests a tubal ligation, you-ve got multiple coding options: a set of codes for procedures performed vaginally or via an open approach, a set of codes for laparoscopic procedures, and a code for Essure tubal ligations.

Note: You-ll always report a tubal ligation with V25.2 (Sterilization), no matter which type of tubal ligation the ob-gyn performs or the reason the patient (or patient's legal guardian) requested the tubal, says Melanie Witt, RN, CPC-OGS, MA, an independent ob-gyn coding consultant in Guadalupita, N.M.

If your ob-gyn uses a laparoscope, you will report either 58670 (Laparoscopy, surgical; with fulguration of oviducts [with or without transection]) for a diathermied tube and 58671 (... with occlusion of oviducts by device [e.g., band, clip, or Falope ring]) if a device occludes the tube.

Look out: If an ob-gyn performs a "minilaparoscopic tubal," you will look to these two codes as well, Witt points out -- but look at the technique to determine which code to use. These two codes differ based on technique regardless of whether the ob-gyn performs the ligation on its own or following a delivery.

If your ob-gyn does not use a laparoscope and performs an open or vaginal procedure, you will report one of these four options:

- 58600 -- Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral

- 58605 -- Ligation or transaction of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure)

- 58611 -- Ligation or transaction of fallopian tube(s) when done at the time of cesarean delivery or intraab-dominal surgery (not a separate procedure) (list separately in addition to code for primary procedure)

- 58615 -- Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring) vaginal or suprapubic approach.

Keep in mind: Sometimes, physicians refer to a tubal procedure as a "Pomeroy tubal," Witt says. This technique involves tying a section of the tube, then removing it. Your ob-gyn can perform this via laparoscope (58670) or via an open procedure (58600, 58605, 58611). You will not report a device code for this technique.

You can report the tubal ligations following a vaginal delivery (59400, 59409-59410). If the tubal ligation occurs immediately after the delivery (during the same operative session), use 58605 with modifier 59 (Distinct procedural service) appended.

Remember: You should use modifier 59 to identify procedures that are distinctly separate from any other procedure the physician provides on the same date, says Suzan Berman-Hvizdash, CPC, CPC-EM, CPC-ED, coding and compliance manager, UPMC-UPP Department of Surgery. In this case, modifier 59 tells the payer the tubal ligation was a distinct service from the delivery even though they occurred during the same session.

Good news: Because the tubal ligation requires a separate incision and is essentially unrelated to the vaginal delivery, carriers that pay for the ligation under other circumstances will generally not take issue with reimbursement using this coding sequence.

Beware: Some carriers may pay less for tubal ligation when reported with modifier 59. Some policies reason that the prep work has already been done for the patient prior to delivery and that there is no need to pay twice for the same work, Witt warns.

Keep in mind: If the tubal ligation occurs a day or more after the delivery (during the same hospital stay), use 58605 with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period). You should receive full reimbursement for the procedure.

Cesarean delivery frequently offers the ob-gyn the chance to perform tubal ligation immediately after the delivery, sparing the patient an additional surgical session. You-ll report 58611 in this case.

Red flag: Billing for tubal ligation at the time of cesarean is almost always a problem with payers because they count the cesarean incision as the incision for the ligation, Witt says. To these insurers, the ligation at the same session does not represent significant effort for the ob-gyn.

Although the American College of Obstetricians and Gynecologists (ACOG) specifically leaves tubal ligation off the list of bundled procedures in its policy on cesarean deliveries and global ob care with cesarean, some carriers will pay little or nothing extra for the procedure, Witt says.

Money saver: Tubal ligation performed at the time of cesarean delivery can prove a significant source of revenue, so practices should negotiate contract renewal to see that the procedure is reimbursed separately from the global package or cesarean delivery codes. "Also, you should point out to the payer that 58611 is an add-on procedure that does not take a modifier," Witt says. The Resource-Based Relative Value Scale (RBRVS) valued this code based solely on the intraoperative work. 

Your ob-gyn can also perform an Essure procedure, which involves implants into the fallopian tubes. For this procedure, you-ll use 58565 (Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants).

Note: If the ob-gyn placed the device in only one tube (for instance, if the other tube was already blocked), you should add modifier 52 (Reduced services) to this code.

Editor's Note: Keep watching future installments of the Ob-gyn Coding Alert to learn how to report a tubal ligation reversal.