Ob-Gyn Coding Alert

New methods for endometrial ablation are here or on the horizon, and although they promise relief for patients, they are bound to bring challenges to ob-gyn coders (see Know the Treatment Options for Endometrial Ablation"" - article 2).

What Is Dysfunctional Uterine Bleeding?

Physicians often use endometrial ablation to treat dysfunctional uterine bleeding which is also known as menorrhagia the formal name for prolonged or excessive menstrual bleeding. In some patients the bleeding is so severe that it causes anemia. Current ICD-9 codes associated with this condition are 626.2 (Excessive or frequent menstruation) 626.4 (Irregular menstrual cycle) 626.6 (Metrorrhagia) 626.8 (Other) and 626.9 (Unspecified).

Many things may cause this condition including a hormonal imbalance abnormal ovulation uterine trauma polyps fibroid tumors cancer cervicitis and other infectious conditions. Irritation from an intrauterine device may also cause menorrhagia or it may be a sign of an ectopic pregnancy.

Coding the Related Services

Until CPT 2001 only one procedure code existed for endometrial ablation. That code 58563 describes the use of a hysteroscope to accomplish the endometrial ablation. CPT added a second code 58353 in 2001 to describe the thermal balloon procedure which is accomplished normally without the use of the hysteroscope.

But how is the coder to know which code to use with the new techniques and what other services can be billed at the time of the procedure? "To begin identify the various types of services provided at the time of the endometrial ablation to see if any can be coded in addition to the procedure " says Melanie Witt RN CPC MA an independent coding consultant and educator based in Fredericksburg Va.

All of the new techniques for endometrial ablation have cervical dilation in common. Because this is an integral part of the procedure you normally would not code it separately if performed at the time of the procedure. Some physicians however may elect to prepare the cervix in advance using a cervical dilator. You can report this procedure separately using 59200 (Insertion of cervical dilator [e.g. laminaria prostaglandin] [separate procedure]).

"Because this is a CPT 'separate procedure ' if the ob-gyn performed the cervical dilation on the same date as the ablation but earlier in the day and the physician has met the criteria for using this modifier modifier -59 (Distinct procedural service) should be added " Witt says. If the insertion took place the day before surgery you would not need to add a modifier. "Also note that because 59200 has a zero-day global period you would not need a modifier for the endometrial ablation code performed the next day either " she adds.

The new methods for performing endometrial ablation may involve the administration of anesthesia. If the anesthesia is a simple local it would be included and not coded separately. If the procedure required a paracervical block (64435) or conscious sedation (99141) many non-Medicare payers will reimburse for it separately. Remember however that the documentation requirements for conscious sedation include pre- and postsedation evaluations of the patient and monitoring of the cardiorespiratory function by an independent trained observer Witt says. In those rare cases when the patient undergoing the endometrial ablation procedure is Medicare-eligible no anesthesia performed by the surgeon will be reimbursed separately.

All of the new techniques involve using equipment and supplies. In many cases although ob-gyns can perform the procedure safely in the office the reimbursement for supplies and equipment is so low that physicians cannot afford to offer the procedure in this setting Witt says. In some cases this problem can be remedied by negotiating a supply or "office facility" fee with the payer. "Doing so would involve convincing the payers of their cost savings when the doctor performs the procedure outside of the hospital while ensuring that the carrier fairly reimburses the practice for the supplies and the equipment used to perform the procedure " Witt explains. If such a fee is not negotiated the practice would be able to seek reimbursement only for a surgical tray (99070 or A4550) which would not cover the cost of higher-priced supplies (e.g. thermal balloons) or the equipment. When the surgeon performs the procedure in an outpatient setting such as an ambulatory surgical center the payer reimburses the center not the physician doing the procedure for the supply and equipment costs.

Coding the New Procedures

Which code should you assign to each of the new techniques and should modifiers be used? Let's take them one at a time:

Thermal balloon procedure When the ob-gyn performs this procedure without using the hysteroscope at any time during the surgical session you would report 58353 (Endometrial ablation thermal without hystero-scopic guidance). If he or she uses the hysteroscope to view the uterus before inserting the balloons assign 58563 (Hysteroscopy surgical; with endometrial ablation [e.g. endometrial resection electrosurgical ablation thermoab-lation]) instead of 58353 Witt says.

Hydro ThermAblator System procedure This procedure involves the use of heat (thermal method) but also involves using a small flexible hysteroscope. As such the correct code for this procedure would be 58563.

Uterine Cryoblation Therapy This procedure involves using extreme cold to ablate the uterus using ultrasound guidance but the ob-gyn generally does not perform hysteroscopy at the same surgical session says Harry L. Stuber MD an independent gynecologist based in Cookeville Tenn. CPT added Category III code 0009T (Endometrial cryoablation with ultrasonic guidance) for this procedure in 2002. "If a Category III code is available this code must be reported instead of a Category I unlisted code " according to CPT guidelines. And in this case there is an exact match.

"Code 58353 would not be correct because although it describes endometrial ablation without hysteroscopy it also describes an ablation performed using heat " Witt says. In addition although you might be tempted to use the code for hysteroscopy with endometrial ablation (58563) with a reduced-services modifier -52 this also would not be correct because CPT guidelines state that coders should not select a CPT code that merely approximates the service provided but should pick either an unlisted-procedure code or as in this case the existing Category III code. Coders do need to be aware that the Category III codes represent emerging technology. As such some payers may decide that the procedure is investigational. Consequently you should provide information to the payer about the procedure and the fact that the FDA has approved it.

NovaSure This procedure uses electrical current to effect cautery of the lining of the uterus. "The closest code would be 58563-52 because this procedure does not normally involve use of the hysteroscope at the same surgical session " Witt explains. This would be considered the most accurate code because CPT gives electrosurgical ablation as an example for 58563 and because some physicians will perform hysteroscopy just prior to the surgery while others will not. Because the CPT definition for modifier -52 reads "a service or procedure is partially reduced or eliminated at the physician's discretion " using the modifier would accurately describe the procedure when the surgeon does not use a hysteroscope.