Urology Coding Alert

You cannot report mesh with all prolapse procedure codes

Note: This is the second article in a series on urogynecological procedures. See the April issue of Urology Coding Alert for information on female urinary incontinence procedure coding.

Female prolapse problems are commonplace in urology and urogynecology practices, and you need to determine the exact type of prolapse and the surgical approach the physician took before you can choose a procedure code. Our experts guide you through each code and explain which codes you should report alone and which you should report together.

Code Mesh With Colporrhaphy, Not Paravaginal Defect Repair

A patient may present to your office with a prolapse of the anterior vaginal wall, which is commonly called a cystocele (618.01, Prolapse of vaginal walls without mention of uterine prolapse; cystocele, midline or 618.02, Prolapse of vaginal walls without mention of uterine prolapse; cystocele, lateral). Your physician will perform either an anterior colporrhaphy or a paravaginal defect repair, so you’ll have to choose between two procedure codes.

For an anterior colporrhaphy, use 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele). If the urologist or urogynecologist also repairs a urethrocele (618.03) you should not separately report its repair because it is included in the code description of 57240.

Bonus: During some anterior colporrhaphy procedures, the surgeon will add mesh to strengthen the repair, says Melanie Witt, RN, CPC-OGS, MA, an independent coding consultant in Guadalupita, N.M. You should report the mesh insertion using +57267 (Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site [anterior, posterior compartment], vaginal approach [list separately in addition to code for primary procedure]). This add-on code requires no modifier or fee reduction and has an unadjusted 2006 Medicare fee of $284.23.

When the surgeon performs a paravaginal defect repair via an open or vaginal approach, report 57284 (Paravaginal defect repair [including repair of cystocele, stress urinary incontinence, and/or incomplete vaginal prolapse]). For a laparoscopic approach, use 49329 (Unlisted laparoscopy procedure, abdomen, peritoneum and omentum), Witt says.

Beware: The National Correct Coding Initiative bundles the Burch procedure, slings, anterior colporrhaphy, and enterocele repair with the paravaginal defect repair, so you cannot report them separately. You also can’t report 57267 for a mesh insertion with 57284 or 49329 even though it is not an NCCI Edits bundle, Witt says. “This is because CPT specifically cites the codes that can be billed together, and CMS does not normally create bundles for code combinations that are clearly spelled out in CPT ,” she adds.

Tip: When adding a mesh to a paravaginal defect repair, append modifier 22 (Unusual procedural services) to 57284 to indicate the extra work involved. Submit a detailed op report as well as a concise explanatory note of the procedure in layman’s terms.

You Have 4 Choices for Vaginal Prolapse Treatment

If a patient has a prolapse of either the uterus or the vaginal vault, your physician will most likely perform a vaginal vault suspension, called a colpopexy. How the surgeon approaches the problem and where he anchors the suspending sutures determine which code you should use to report the procedure.

If the urologist or urogynecologist uses an abdominal approach and attaches the vaginal vault to the sacrum, you should report the colpopexy with 57280 (Colpopexy, abdominal approach), says Nina Mutone, MD, medical director of the urogynecology division at St. Vincent’s Hospital in Indianapolis. If the physician uses a transvaginal approach, you should report 57282 (Colpopexy, vaginal; extra-peritoneal approach [sacro-spinous, iliococcygeus]).
 
A third type of vaginal vault suspension involves an intraperitoneal vaginal approach. For this procedure, you would use 57283 (Colpopexy, vaginal; intraperitoneal approach [uterosacral, levator myorrhaphy]).

Another option: If your urologist or urogynecologist incorporates a laparoscopic approach, you’ll use yet another code, Witt says: 57425 (Laparoscopy, surgical, colpopexy [suspension of vaginal apex]).

Caution: Don’t report the addition of mesh using 57267 with the colpopexy codes, because you can only use 57267 as an add-on code with 45560 (Repair of rectocele [separate procedure]), 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele), 57250 (Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy), 57260 (Combined anteroposterior colporrhaphy), and 57265 (Combined anteroposterior colporrhaphy; with enterocele repair).

Look at Approach for Rectocele Repair Coding

Two other prolapse problems your physician might repair are rectocele (618.04, Prolapse of vaginal walls without mention of uterine prolapse; rectocele) and enterocele (618.6, Vaginal enterocele, congenital or acquired), and each has its own procedure code options.
 
“A rectocele repair is the repair of a prolapse of the back wall of the vagina between the vagina and the rectum,” Mutone says. For this procedure, report 45560 (Repair of rectocele [separate procedure]) if the physician doesn’t also perform a posterior colporrhaphy. If he performs the repair with a posterior colporrhaphy, use 57250 (Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy) or 57260 (Combined anteroposterior colporrhaphy).

To repair an enterocele, the surgeon will use either an abdominal or a vaginal approach. For the vaginal approach, report 57268 (Repair of enterocele, vaginal approach [separate procedure]), and for the abdominal approach report 57270 (Repair of enterocele, abdominal approach [separate procedure]). Be aware that because CPT labels these procedures “separate procedure,” NCCI bundles them into most other procedures. Check your  individual payer rules before billing these codes.