Pediatric Coding Alert

Question: We are having an issue in our pediatric office regarding 56441. The patient had a vaginal adhesion which was corrected simply in the doctor's office. The problem is that the patient is getting charged a higher copay because of the surgical coding used. I have looked in the CPT book and asked many certified coders how this should be coded since an actual "surgery" was not performed. They are all stumped. Do you have any suggestions?

Ohio Subscriber

Answer: Your coding seems appropriate. For removal of labial adhesions, which is performed using a blunt instrument or scissors under general or local anesthesia, you should report 56441 (Lysis of labial adhesions). In a non-facility setting, the code has 3.94 relative value units (RVUs), according to the 2009 Medicare Physician Fee Schedule, which you can use to judge private payers' rates. The procedure includes a 10-day global period, which a payer may follow. You would link 54661 to 752.49 (Other anomalies of cervix, vagina, and external genitalia).

Some insurers have a higher copay for codes in the surgery section of CPT. Insurers may treat minor procedures as "surgeries."

Do this: Explain to the parent that you have appropriately coded for the work involved in opening the adhesion. Suggest the parent contact her employer's human resources director to discuss the various rates.

The insurance plan that the patient has determines the patient's copay. The parent, not your office, has the responsibility to discuss variations in code-triggered copays with the plan/employer/human resources department. You, however, are legally obligated to correctly report the work performed, and cannot change your coding for payment (the patient's or your) benefit.