Outpatient Facility Coding Alert

Question: We’re seeing more denials than usual for procedures involving vaginal mesh. What’s going on?

Answer: If surgeons in your ASC or HOPD perform gynecological procedures, you’ve had some CCI edits to contend with since Jan. 1, 2017. However, many facilities have missed these edits and are seeing denials and delays, remarked Amy C. Pritchett, BSHA, CPC, CPC-I, CANPC, CASCC, CEDC, CASCC, CRC, CCS, CDMP, CMPM, ICDCT-CM, ICDCT-PCS, CMRS, C-AHI, who spoke at the American Academy of Professional Coders’ recent Healthcon in Las Vegas, Nevada.

The vaginal mesh add-on code +57267 is now bundled into the following codes:  

• 57268 (Repair of enterocele, vagina approach [separate procedure]), and
• 57288 (Sling operation for stress incontinence [eg, fascia or synthetic]).

Each of the above-mentioned edit pairs (57268 or 57288 with +57267) carries a modifier indicator of “1,” meaning that you might be able to report both codes in an edit pair if you have sufficient documentation to support separate coding. “The edit can be overcome, if appropriate, with the use of modifier 59 (Distinct procedural service),” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania. If so, you should append a modifier to the Column 2 code. This should be an exception and not the rule, and you’ll need supporting documentation to back up your claim. Note, however, that 57268 when paired with 57288 has a modifier indicator of “0,” and thus, they should never be reported together on the same date of service. 

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