OB/Gyn Codes Clarified for 2008
Changes Include New Hysterectomy Codes, Rules
By Renée Dustman, Senior Editor
Although we may not have all agreed on how to code certain OB/GYN procedures in the past, some recent changes to CPT® leave little room for future disagreement. When it came to reporting total laparoscopic hysterectomies, for example, some experts advised coders to use the unlisted procedure code while others recommended using the existing laparoscopic-assisted hysterectomy code with modifier 52. The new and revised codes for total laparoscopic hysterectomies and other procedures that fall within the female genitourinary section of CPT® 2008 enable us to be more specific.
Peritoneal Tumor Ablation
The American Medical Association (AMA) retired CPT® codes 49200 Excision or destruction, open, intra-abdominal or retroperitoneal tumors or cysts or endometriomas; and 49201 Excision or destruction, open, intra-abdominal or retroperitoneal tumors or cysts or endometriomas; extensive and added codes 49203-49205 for 2008. Use these new codes to report excision of ovarian and other malignancies when the primary organs (i.e., uterus, tubes and ovaries) have already been resected. You can also use these codes to report non-cancerous conditions, such as endometriomas or cysts.
49203 Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less
49204 …largest tumor 5.1 to 10.0 cm diameter
49205 …largest tumor greater than 10.0 cm diameter
The code you select depends on the size of the largest tumor removed during a single session. Do not code each tumor, just the largest one. For example, if the doctor removes one tumor with a diameter of 5 centimeters, a second with a diameter of 5.1 centimeters and a third tumor with a diameter greater than 10 centimeters, you should submit code 49205 for the removal of all three tumors. You should not use these codes to report the excision of uterine fibroids or ovarian masses, which have their own codes.
Paravaginal Defect Repair
The traditional approach for repairing paravaginal defects repairs was through the abdomen. The vaginal approach, however, has become more popular; and the newer laparoscopic approach is advancing. To accommodate the changing tides, the term “open abdominal approach” for paravaginal defect repair was added to code 57284; and codes 57285 and 57423 were created to specify the alternate approaches (vaginal or laparoscopic, respectively). The wording “repair of stress urinary incontinence and/or incomplete vaginal prolapse” was deleted from 57284. The result is a group of codes that give us a much clearer way to report these procedures and get paid accordingly.
57284 Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach
57285 …vaginal approach
57423 …laparoscopic approach
When selecting these codes, check the documentation carefully and note the type of cystocele performed, if applicable. A cystocele due to the disruption of the vaginal attachments to the arcus tendineus is call a lateral defect cystocele and is covered under these codes. A central defect cystocele is not.
The AMA guidelines recommend you should not report 57284 in conjunction with 51840, 51841, 51990, 57240, 57260, 57265, 58152, 58267; or 57285 in conjunction with 51990, 57240, 57260, 57265, 58267; or 57423 in conjunction with 49320, 51840, 51841, 51990, 57240, 57260, 58152, or 58267.
Tip: For those offices doing incontinence, make sure to read the new CPT® guidelines carefully before selecting your codes.
Excision of Cervix
A physician may perform a cervical biopsy to examine cervical tissue under a microscope for abnormalities. An abnormal Pap smear is often the impetus for this procedure. A simple cervical biopsy removes a small piece of tissue from the surface of the cervix. This procedure is usually done in the physician’s office, clinic or hospital as an outpatient procedure. To ensure the proper use of procedural code 57500, the term “cervix” was added to the descriptor.
57500 Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure)
Total Laparoscopic Hysterectomy
All hysterectomies involve removal of at least the uterus. A total hysterectomy involves removing both the uterus and cervix. It may also include removal of ovaries and fallopian tubes. Traditional approaches for a total hysterectomy are through the abdomen or vagina. A newer approach is to use laparoscopy. Not to be confused with laparoscopic assisted vaginal hysterectomy (LAVH) or laparoscopic hysterectomy (LH), a total laparoscopic hysterectomy (TLH) occurs when the entire hysterectomy is performed laparoscopically. Previously, we had no specific codes for TLH procedures and typically used unlisted codes, so the following new codes are a welcome addition.
58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 grams or less;
58571 …with removal of tube(s) and/or ovary(s)
58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 grams;
58573 …with removal of tube(s) and/or ovary(s)
These codes are divided by weight of the uterus so make sure your physician documents this clearly. It’s also essential to identify the approach correctly. Remember that if any part of the procedure is done through the vagina, you should use LAVH codes instead. You should not report 58570-58573 in conjunction with 49320, 57000, 57180, 57410, 58140-58146, 58150, 58545, 58546, 58561, 58670, 58671.
Even though we got some new code changes this year, it shouldn’t bring too many changes to our practice. The CPT® clarifications were well warranted but without controversies; and the addition of the hysterectomy codes are a welcome addition to the family.