Stop Poor Uterine Fibroid Coding
Before It’s a Growing Concern
By Vinoth Ramdass, BPT, CPC
Fibroids are benign growths in the womb’s muscle. They are common, especially in older women. Many women with fibroids are fertile and have no problems delivering a pregnancy, but if the fibroid significantly distorts the cavity of the womb, it may interfere with embryo implantation. Fibroids may also displace the fallopian tubes and ovaries.
Because fibroids are almost always benign, it is rare (less than one in 1,000 cases) for a cancerous fibroid (leiomyosarcoma) to occur. No one knows for sure what causes fibroids. We do know, however, they are under hormonal (both estrogen and progesterone) control. Fibroids grow rapidly during pregnancy, when hormone levels are high, and shrink when anti-hormone medication is used. They also stop growing and may shrink when a woman reaches menopause.
Location Determines Diagnosis Code
ICD-9-CM coding depends on the fibroid’s exact location. Most fibroids grow within the uterus wall. These are known as intramural fibroids and are reported using 218.1 Intramural leiomyoma of uterus (interstitial leiomyoma of uterus). Whereas submucosal fibroids (218.0 Submucous leiomyoma of uterus) grow into the uterine cavity; and subserosal fibroids (218.2 Subserous leiomyoma of uterus) grow outside of the uterus.
Other fibroids grow on stalks from the uterus’ surface or in the uterus’ cavity (they might look like mushrooms). These are called pedunculated fibroids and are reported with 218.9 Leiomyoma of uterus, unspecified. You should also report 218.9 if the provider does not specify the location of the uterine fibroid.
Diagnostic Procedure Codes
The physician may perform imaging tests to confirm fibroids. These tests might include:
Ultrasound—The ultrasound probe can be placed on the abdomen or inside the vagina. For pelvic exam, report 76856 Ultrasound, pelvic (nonobstetric), real time image documentation; complete. For transvaginal examination, use 76830 Ultrasound, transvaginal.
Magnetic resonance imaging (MRI)—Report MRI using 74181-74183, as appropriate.
X-rays—Report with code 74020 Radiologic examination, abdomen; complete, including decubitus and/or erect views.
Computed tomography (CT) scan—For procedures without contrast, select from 74150 Computed tomography, abdomen; without contrast material or 72192 Computed tomography, pelvis; without contrast material, depending on location. For procedures with contrast, consider either 74160 Computed tomography, abdomen; with contrast material(s) or 72193 Computed tomography, pelvis; with contrast material(s).
Hysterosalpingogram (HSG) or sonohysterogram (SIS)—An HSG involves injecting dye into the uterus and taking X-ray pictures. A sonohysterogram involves injecting water into the uterus and taking ultrasound pictures. You should report either of these procedures with 58340 Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalphingography.
For a HSG, the corresponding radiological supervision and interpretation code is 74740 Hysterosalpingography, radiological supervision and interpretation. For a SIS, the appropriate code is 76831 Saline infusion sonohysterography (SIS), including color flow Doppler, when performed.
The physician may also perform hysteroscopy to confirm fibroids. The doctor passes a long, thin scope with a light through the vagina and cervix into the uterus; no incision is needed. The doctor can look inside the uterus for fibroids and other problems, such as polyps. Report 58555 Hysteroscopy, diagnostic (separate procedure) for a simple diagnostic hysteroscopy for this procedure. Code 58555 is designated as a “separate procedure” according to CPT® guidelines and would not be billable if a more extensive procedure is performed hysteroscopically. If a biopsy is taken, report instead 58558 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and /or polypectomy, with or without D & C.
Surgical Treatment Options
A physician may recommend surgery as the treatment of choice for fibroids with moderate to severe symptoms. Surgical options include the following:
Myomectomy—Fibroids are removed without taking healthy uterus tissue. It is best for women who wish to have children after fibroid treatment, or who simply wish to keep their uterus intact. Myomectomy can be accomplished as an open or laparoscopic procedure.
To report an open procedure, you must know the approach and total number and/or weight of removed fibroids:
58140 Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; abdominal approach
58145 Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach
58146 Myomectomy, excision of fibroid tumor(s) of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g, abdominal approach
Note: There is no vaginal approach procedure code for fibroids larger than 250 grams because they are generally too large to be removed vaginally.
For laparoscopic myomectomy, turn to 58545 Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myoma(s) or 58546 Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g.
Regardless of approach, when five or more fibroids are removed, or when the combined weight of all fibroids removed exceeds 250 grams, the CPT® codes representing these services will reimburse at a higher rate. Documentation should specify the number and weight of the fibroids, to ensure payment reflects how much work was done.
Hysterectomy—Uterus removal is the only certain way to cure uterine fibroids. For a hysterectomy performed via the abdomen, look to code range 58150-58240. For a hysterectomy by vaginal approach, select a code from 58260-58294. Final code selection will depend on uterus size/weight, the extent of uterus removed, and any additional procedures performed.
In some cases, hysterectomy may be performed laparoscopically. Code choice will depend on the extent of the removal, as well as the uterus’ size, and whether the tubes and/or ovary(s) are removed at the same time.
Laparoscopic supracervical hysterectomy:
58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less;
58542 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g;
58544 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
Laparoscopic vaginal hysterectomy:
58550 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less;
58552 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58553 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g;
58554 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
Laparoscopic total hysterectomy:
58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less;
58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g;
58573 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
Endometrial ablation—In this procedure, the lining of the uterus is removed or destroyed to control bleeding. It may be performed with laser, wire loops, boiling water, electric current, microwaves, freezing (cryoablation), or other methods. This procedure can be done on an outpatient basis. Approximately half of the women who have this procedure stop menstruating, and three in 10 women have much lighter bleeding. A woman cannot have children after this surgery, however.
You must choose between hysteroscopic (58563 Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation)) and nonhysteroscopic (58353 Endometrial ablation, thermal, without hysteroscopic guidance) methods when selecting an endometrial ablation code. For cryoablation with ultrasonic guidance, report instead 58356 Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed.
Myolysis—This procedure uses a needle inserted into the fibroids, usually guided by laparoscopy. When activated, various energy sources (such as, neodymium-doped yttrium aluminium garnet (Nd: YAG) laser, bipolar electrocautery, cryotherapy, radiofrequency ablation) induce fibroid devascularization and ultimately target tissue ablation. When the Ob/Gyn uses radiofrequency, the procedure is known as Hysterectomy Alternative (HALT).
Report myolysis using Category III code 0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue or 0072T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater than or equal to 200 cc of tissue.
Remember: You must use a Category III code if it is available. Do not report an unlisted-procedure code unless a payer instructs you to do so in writing.
Uterine fibroid embolization (UFE) or uterine artery embolization (UAE)—During this procedure, a thin tube is threaded into the blood vessels supplying blood to the fibroid. Next, tiny plastic or gel particles are injected into the blood vessels. This blocks the blood supply to the fibroid, causing it to shrink. UFE can be an outpatient or inpatient procedure.
Report UFE using 37210 Uterine fibroid embolization (UFE, embolization of the uterine arteries to treat uterine fibroids, leiomyomata), percutaneous approach inclusive of vascular access, vessel selection, embolization and all radiological supervision and interpretation, intra procedural roadmapping and imaging guidance necessary to complete the procedure. Note that this code “includes all catheterization and intraprocedural imaging required for a UFE procedure to confirm the presence of previously known fibroids and to roadmap vascular anatomy to enable appropriate therapy.”
There is not a separate HCPCS Level II code to report for microspheres, but some non-Medicare payers will allow separate payment for supplies in the office setting with 99070 Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided).
Vinoth Ramdass, BPT, CPC, holds a bachelor of physiotherapy from M.G.R. Medical University, India, and a diploma in acupuncture. He currently works as an executive coder for Perot Systems Business Process Solutions.