Ob-Gyn Coding Alert

And you should code it that way

Insurance carriers may argue that genital prolapse repair is included in other procedures, but don't give up. As long as you can prove medical necessity, you can get paid.
 
Ob-gyns frequently use vaginal vault suspension to correct vaginal prolapse following a hysterectomy when the top of the vagina breaks away from the uterosacral ligaments that once held it in place. If the physician does not reattach the uterosacral ligaments to the vagina during the initial hysterectomy, prolapse can occur.

You Have 3 Choices for Prolapse Treatment Alone

 
Where the surgeon anchors the uterosacral ligaments determines which code you should use for the vaginal vault suspension. If the ob-gyn uses an abdominal approach and attaches the vaginal vault to the sacrum using mesh, you should report a colpopexy with 57280 (Colpopexy, abdominal approach), says Donna C. Kroening, CPC, reimbursement manager for the ob-gyn department at the Medical College of Wisconsin in Milwaukee.
 
On the other hand, if the physician uses a transvaginal approach, you should report 57282 (Sacrospinous ligament fixation for prolapse of vagina). During this procedure, the surgeon makes an incision in the top of the vaginal wall's posterior and sews the prolapsed vaginal wall to the sacrospinous ligament between the sacrum and the right or left pelvic bone, Kroening explains.
 
A third type of vaginal vault suspension incorporates a laparoscopic approach. Called a laparoscopic uterosacral ligament suspension, the ob-gyn attaches the uterosacral ligament to the top of the vagina. This is different from the traditional colpopexy because the surgeon performs it laparoscopically. Fortunately, CPT 2004 includes a new code for this procedure, says Brenda Dombkowski, CPC, a coding specialist at Obstetric-Gynecology & Infertility Group in Cheshire, Conn. You should report the laparoscopic vaginal vault suspension as 57425 (Laparoscopy, surgical, colpopexy [suspension of vaginal apex]) after Jan. 1, 2004, she adds.
 
"Our practice does not do it laparoscopically because it's not proven to be very effective," Kroening says. Her ob-gyns feel that the procedure is more effective when performed vaginally (57282).

Hysterectomy Causes Coding Complications

Ob-gyns often run into problems when billing a vaginal vault suspension at the same time as a hysterectomy. Although the American College of Obstetricians and Gynecologists (ACOG) states that in the case of total or subtotal abdominal hysterectomies "repairs or suspension procedure of vagina, urethra and perineum" are "examples of intraoperative services excluded from the global service," many carriers deny the suspension for lack of medical necessity. They argue that the suspension procedure is preventive rather than restorative at the time of the hysterectomy because the physician performs it to prevent the prolapse from happening in the future.
 
Generally, you can bill for the suspension if the payer does not bundle it into another procedure for which you are coding. For instance, Medicare includes 57280 in 58150 (Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]), and you cannot bypass the edit. But Medicare does not bundle 57282 into any of the hysterectomy codes.
 
For non-Medicare carriers and those that don't use the Medicare bundling edits, you should report the suspension procedure in addition to the hysterectomy. Append modifier -51 (Multiple procedures) to the vaginal vault suspension code.
 
Because 57282 includes the phrase "for prolapse of vagina," you should not report it with a hysterectomy unless the vaginal prolapse already occurred before the two procedures. Also, ICD-9 does not include a code for "prevention of vaginal prolapse." But you may be able to support billing 57282 with a hysterectomy if your physician's documentation shows why he or she decided to perform the suspension and if statistical material supporting vaginal vault suspension at the time of hysterectomy to prevent prolapse can back this up.
 
If the surgeon performs a vaginal vault suspension without a genital prolapse diagnosis (618.x), Medicare will not pay for the additional procedure at the time of hysterectomy. If you have the prolapse diagnosis, however, Medicare generally will reimburse both the hysterectomy and the suspension, as long as you link the diagnosis codes appropriately.