Five Common OB/GYN Scenarios Reveal Coding Answers
By Peggy Stilley, CPC, CPC-I, COBGC, ACS-OB
Scenario No. 1: Preventive Exams—Well Woman
Medicare generally does not pay for preventive exams; however, an allowance was made for the breast, Pap, and pelvic exam (BPP). Medicare pays for a BPP exam every year for those women who:
A.) are of childbearing age and have had an examination indicating the presence of cervical or vaginal cancer or other abnormalities during any of the preceding three years; or
B.) are considered high risk for developing cervical or vaginal cancer.
A high-risk patient is one who has:
- Engaged in sexual activity before the age of 16;
- Had multiple sexual partners (more than five in a lifetime);
- A history of a sexually transmitted disease (including the human papillomavirus and/or HIV infection); and/or
- Had fewer than three negative Pap tests within the previous seven years.
For all other woman, defined as “low risk,” Medicare will pay for a BPP exam every two years. An overview of coverage and risk criteria may be found on the CMS website at www.cms.hhs.gov/CervicalCancerScreening/.
To qualify for Medicare coverage, a screening pelvic exam must include at least seven of the following 11 elements:
- Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge;
- Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses;
Pelvic examination (with or without specimen collection for smears and cultures) including:
- External genitalia (for example, general appearance, hair distribution, or lesions);
- Urethral meatus (for example, size, location, lesions, or prolapse);
- Urethra (for example, masses, tenderness, or scarring);
- Bladder (for example, fullness, masses, or tenderness);
- Vagina (for example, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele);
- Cervix (for example, general appearance, lesions, or discharge);
- Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support);
- Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity); and
- Anus and perineum.
Reporting and reimbursement for BPP services requires specific HCPCS Level II and ICD-9-CM codes. A full listing of covered HCPCS Level II and ICD-9-CM codes, along with instruction for applying the codes and the minimum exam requirements listed above, is found in the Medicare Claims Processing Manual, chapter 18, sections 30 “Screening Pap Smears” and 40 “Screening Pelvic Exams” (www.cms.hhs.gov/manuals/downloads/clm104c18.pdf).
Providers may recommend to a patient certain exams, tests, or services that are not a covered benefit (for instance, the physician may recommend a BPP exam for a low-risk Medicare beneficiary at a frequency greater than two years since the previous exam). It is the provider and staff’s responsibility to let the patient know the service may not be covered, or the service has frequency guidelines. Coders must educate themselves: Know which services need an Advanced Beneficiary Notice (ABN), and whether modifiers are required for payment or are informational only. Bookmark the Centers for Medicare & Medicaid Services’ (CMS) website in your “favorites” menu, and be aware of local coverage determinations (LCDs) for your Medicare payer.
Scenario No. 2: Global Surgical Package
The services you’ll include, or bundle into, the global surgical package will depend on the payer for a particular claim. The global surgical package as defined in CPT® includes:
- Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
- One related evaluation and management (E/M) encounter on the date immediately prior to or on the date of the procedure (including history and physical) once the decision for surgery is made
- Immediate postoperative care; including dictating operative notes, talking with the family and other physicians
- Writing orders
- Evaluating the patient in the post-anesthesia recovery area
- Typical postoperative follow-up care
Global days associated with procedures are zero, 10 days, or 90 days. Obstetrical care is defined as global for six weeks past the delivery date.
CMS does not follow CPT® guidelines, however. The Medicare surgical package includes:
- Pre-op visits
- —Day before surgery for 90 day global
- —Day of surgery for 0-10
- Complication following the surgery—unless return to OR
- Post-op visits (related to recovery from procedure)
- Post-surgical pain management provided by surgeon
- Miscellaneous services (dressing changes, staple, drain, tube removal, etc; local incision care, etc.)
So, for instance, whereas a payer who follows CPT® guidelines may allow separate payment for an office E/M service to treat a surgery complication during the global period, Medicare will not allow separate payment unless the patient must return to the operating room.
Be aware of surgical guidelines when contracting with private payers. Inquire whether they follow CPT® or Medicare guidelines.
Scenario No. 3: Endometrial Ablations
Many companies produce a variety of equipment to accomplish ablations. Some instruments incorporate heat, while others use cold. When performing a thermal (heat) ablation, options include loops, roller balls, etc. Thermal ablation may be reported using either 58563 Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation) or 58353 Endometrial thermal ablation without hysteroscopic guidance at any time during the ablation, depending on whether the hysteroscope is used. Cyroablation (use of cold) is reported with 58356 Hysteroscopic endometrial cryoablation, including endometrial curettage, when performed.
When reporting endometrial ablations, consider also:
- Any use of hysteroscope can be billed as a hysteroscopic procedure.
- Place of service is critical to reimbursement. For instance, billing 58356 in your office renders 45.55 relative value units (RVUs), while the same procedure performed in a facility is valued at 9.71 RVUs. The higher non-facility reimbursement covers the equipment and administrative costs of running your office.
- National Correct Coding Initiative (CCI) edits apply to Medicare. CCI does not allow the provider to bill separately for anesthesia. Private payers may allow this, however; if so, bill for the para-cervical block (64435 Injection, anesthetic agent; paracervical (uterine) nerve).
Scenario No. 4: Urodynamics
With an aging population (and increased public awareness), urinary incontinence is no longer a forbidden topic. Patients are encouraged to discuss their problem, and physicians are educated about testing and surgical options available. CPT® 2010 offered several revisions to urodynamic testing codes, as well as new and “resequenced” codes.
51726 Complex cystometrogram, calibrated electronic equipment
51727 with urethral pressure studies, any technique
51728 with bladder voiding pressure studies, any technique
51729 with bladder voiding pressure studies, urethral pressure studies, any technique
+51797 Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure). [This code is resequenced as well as revised.]
Urodynamic testing generally is performed by specially-designed equipment (calibrated electronic equipment), which contains graphs and/or images. From those graphs or images, a provider interprets the patient’s condition and makes recommendations about treatment, therapy, or surgery that is translated into a written report.
Cystometrogram measures how well the bladder stores and empties urine; for instance, for patients with symptoms of urinary incompetence. The procedure must be performed by, or under the direct supervision of, a physician, with all supplies provided by the physician. If the physician only interprets the results and/or operates the equipment, append modifier 26 Professional component to identify the physician’s services.
Voiding pressure studies may measure pressure either just in the bladder or in the bladder and abdomen simultaneously (as described by 51797). Subtracting the voiding abdominal pressure from the total bladder pressure on voiding gives the most accurate determination of true voiding pressure, also known as detrusor pressure. As an add-on procedure, 51797 may be reported with 51728 or 51729, which include bladder voiding pressure only. The procedure must be performed by—or under the direct supervision of—a physician, with all supplies provided by the physician.
Scenario No. 5: Adhesiolysis
Lysis of adhesions may be billed separately—either by reporting a separate CPT® code (see below) or by adding modifier 22 Increased procedural services to the primary procedure code—depending on the adhesions’ extent and based on the procedure’s documentation.
Documentation is crucial as the surgeon must describe the adhesions in the same manner that a writer describes a situation in a novel. It must tell a story giving a clear picture describing the difficulty encountered in the procedure. Did the adhesions distort the anatomy? Were they dense and fiberous? How much time was spent removing the adhesions before seeing the surgical field?
For example, the physician’s documentation might specify: “There were dense adhesions from the bladder to the uterus appearing to have grown to the patient’s uterus from a prior cesarean. These were carefully dissected with the Harmonic scalpel. Approximately one hour of extra operating time was utilized in attempting to dissect the bladder from the uterus. This was very tedious given that the adhesions were so dense and there was not a good operating plane and this made the dissection very difficult.”
In this case, appending modifier 22 to the primary procedure code is justified, along with a request for additional payment based on the unusually difficult or time-consuming nature of the procedure.
When coding separately for adhesions using a dedicated CPT® code, select an appropriate code based on location:
- Tubes and ovaries, 58660 Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) or 58740 Lysis of adhesions (salpingolysis, ovariolysis)
- Peritoneal or pelvic viscera, 58662 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
- Intrauterine, 58559 Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method)
- Labial, 56441 Lysis of labial adhesions
- Urethral, 53500 Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (eg, postsurgical obstruction, scarring)
- Intestinal adhesions, 44005 Enterolysis (freeing of intestinal adhesion) (separate procedure) or 44180 Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure)
For example, significant dense adhesions were dissected from the omentum to the anterior abdominal wall and left pelvic sidewall. In this case, report 44180.