Ob-Gyn Coding Alert

The key to stress urinary incontinence (SUI) coding is determining the surgeon's approach -- either abdominal or vaginal.

SUI is urine leakage that occurs when a woman engages in an activity such as laughing, lifting, or sneezing. These activities place pressure or stress on the bladder. SUI can result from a wide variety of causes, including vaginal deliveries, obesity, pelvic tumors, or chronic constipation.

Ob-gyns treat SUI with pelvic floor exercises,devices that block urine loss, or surgery. Surgery generally involves suspending the urethra, says Peggy Stilley, CPC-OGS, ACS-OB, clinic manager at OU Physicians in Tulsa, Okla. When the physician and patient choose surgery, however, not all the procedures are equal from a coding perspective.

If the surgeon chooses an abdominal approach for the urethral suspension, you should consider 51840 (Anterior vesicourethropexy, or urethropexy [e.g.,Marshall-Marchetti-Krantz, Burch]; simple) or 51841 (... complicated [e.g., secondary repair]), Stilley says.

During the Marshall-Marchetti-Krantz (MMK) procedure,the ob-gyn places sutures into the vaginal wall at the level of the urethra or bladder neck and anchors them to the pubic bone. For a Burch sling procedure, the surgeon would anchor the sutures to the Cooper's ligament.

You would designate the MMK or Burch surgery as complicated -- and therefore use 51841-- as long as your claim meets some of the following examples and the documentation clearly supports these situations:

- The procedure is a secondary repair.

- The patient has extensive bleeding during surgery.

- The patient has adhesions from a previous surgery.

- The patient has vaginal prolapse.

- The procedure takes an excessive amount of time to complete.

- The patient is obese.

Ob-gyns also may use a vaginal approach to correct incontinence. In this case, you most often would report 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele), says Connie Craig, CPC, a consultant in Kansas City, Mo. During this procedure, the surgeon folds redundant prolapsed tissue under the urethra and/or bladder neck to help support the structure.

On the other hand, the physician may use a combined vaginal and abdominal approach to perform a suburethral sling operation. Here, you would report 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]).

During this procedure, the ob-gyn places fascia or other materials at the urethrovesical junction to encircle and suspend the urethra, according to CPT Assistant June 2002. The surgeon pulls the ends of the sling toward the symphysis pubis and fastens them to the rectus abdominus sheath.

In addition to the combined approach, you should use 57288 when your ob-gyn addresses SUI with tension-free transvaginal tape (TVT), Craig says. During this procedure, the surgeon places the TVT sling, providing new support to tissue with less morbidity than traditional sling procedures. Because the physician doesn't have to harvest graft material, she makes fewer incisions.

What happens: The doctor makes one incision into the vagina and inserts a synthetic tape between the vagina and abdominal wall. Within four to six weeks, tissue grows around the tape and holds it in place. This, in turn, supports the bladder neck. In addition, each patient's TVT operation is individualized, thus reducing the chance that the patient will need a catheter for a prolonged time after the operation.