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Ob-Gyn Coding Alert

ABCs of Biopsies A Diagnostic Coding Primer

Published on Wed May 01, 2002

Latest Question on CPT Code 58100 for Endometrial Biopsy from Codify's Ask an Expert Forum

Question: A new patient comes in for excessive menses for 20 days. The ob-gyn discusses the options and orders blood work. The ob-gyn makes the decision to do a biopsy at this visit. I reported 99203-57 and 58100. My payer denied the E/M as bundled, but that doesn't make sense. How would the ob-gyn know she was going to do a biopsy at this visit when the patient was new? Should I appeal?

Texas Subscriber

Answer: Yes, you should appeal the denial. Many times, you cannot make a case for an established...

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Coding for gynecological biopsies when performed as stand-alone procedures or in conjunction with other services constitutes significant revenue for many ob/gyn practices. Frequently, biopsies are done because of suspected malignancies but come back negative. This is good news for the patient but presents a coding problem when it comes to showing medical necessity. An understanding of the different types of biopsies, documentation requirements, and which ICD-9 codes need to be linked for proper reimbursement means fewer billing errors and more accurate reimbursement.

Reporting a justifying ICD-9 code is more important than ever before says Melanie Witt RN CPC MA an independent coding educator and ob/gyn coding expert because payers consistently look for close diagnostic matches before paying for expensive procedures. The payer is looking for a match between the procedure and reason for doing it and it is the payer who decides whether the code used justifies the procedure per their coverage policy " she says. In addition due to the many possible diagnoses and their often slight variations from one another coders must be particularly diligent in choosing the right ICD-9 code.

Biopsy Basics

Simply put a biopsy is a tissue sample that is excised from the patient to ascertain the presence of cancer. In the gynecological setting physicians are most likely to perform biopsies of the vulva cervix vagina endometrium and ovary(s). Biopsies can be ordered as a result of abnormal vaginal bleeding or after the detection of a mass cyst lump tumor or cells of abnormal appearance.

Endometrial Biopsy This procedure extracts samples from the tissue lining (endometrium) the inside of the uterus. A plastic catheter is inserted into the uterus and a small amount of the endometrial lining is suctioned out. The procedure is done vaginally either alone or in conjunction with other gynecological surgery. The procedure can be ordered as a result of several diagnoses. The most common reasons for performing an endometrial biopsy are abnormal uterine bleeding (626.6 626.9) amenorrhea (626.0) and menopausal and postmenopausal disorders (627.0 627.1 627.9). Secondary diagnoses or those recorded in the absence of other symptoms are history or family history of cancer (V10.41 V10.42 V10.44 V16.49) and estrogen therapy (V07.4).

CPT has two codes for endometrial biopsy: 58100* (Endometrial sampling [biopsy] with or without endocervical sampling [biopsy] without cervical dilation any method [separate procedure]) and 58558 (Hysteroscopy surgical; with sampling [biopsy] of endometrium and/or polypectomy with or without D & C). Code 58100 defines a fairly straightforward procedure that can be done in the office without general or local anesthesia in most cases. As a starred code the procedure includes no pre- or postoperative care or global period. Code 58100 can be billed in conjunction with a preventive or problem-oriented E/M visit by attaching modifier -25 to the E/M code for a significant separately identifiable E/M service by the same physician on the same day of the procedure or other service. If the patient reports for a biopsy and no other service is planned or conducted however the biopsy code is billed on its own and no E/M service is reported.

The biopsy portion of 58558 is part of a larger procedure performed under anesthesia. The biopsy is taken intraoperatively during hysteroscopic surgery and may be interpreted while the patient is still in surgery. If the biopsy indicates malignancy the surgeon may advance the procedure to include an excision of abnormal tissue/cells or even a hysterectomy.

Other ICD-9 codes that may be reported to justify the endometrial biopsy (58100) in addition to the diagnoses listed above include malignant neoplasm of body of corpus uteri (182.0) submucous leiomyoma of uterus (218.0) hypertrophy of labia (624.3) excessive or frequent menstruation (626.2) and irregular menstrual cycle (626.4). Diagnostic codes that support 58558 include malignant neoplasm of isthmus (182.1) benign neoplasm of corpus uteri (219.1) carcinoma in situ of cervix uteri (233.1) uteran neoplasm of uncertain behavior (236.0) endome-triosis of uterus (617.0) and hypertrophy of uterus (621.2).

Ovarian Biopsy An ovarian biopsy is the only way to conclusively diagnose ovarian cancer which has the seventh highest cancer mortality rate in women. Consequently once a lump or mass is detected on the ovary it is removed surgically then biopsied intraoperatively. If pathology indicates malignancy the surgeon may opt to continue the surgery to determine if the cancer has spread and may decide to remove one or both ovaries.

The code for ovarian biopsy is 58900 (Biopsy of ovary unilateral or bilateral [separate procedure]). As a surgical procedure this biopsy can be performed either through an open incision (laparotomy) or laparoscopically. If it is performed laparoscopically (49321 Laparoscopy surgical; with biopsy [single or multiple]) and the intraoperative biopsy reveals malignancy the surgeon may convert to an open procedure to remove the ovary(ies) (e.g. 58950 Resection of ovarian tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentect-omy). At this point most payers will consider the biopsy part of the more extensive procedure but some may reimburse 58900 separately. If the work involved in obtaining the biopsy was significant and well-documented modifier -22 (Unusual procedural services) paired with written documentation may help to obtain a higher reimbursement.

For 58900 or 49321 some of the more frequently reported diagnoses include malignant ovarian neoplasm (183.0) benign ovarian neoplasm (220) neoplasm of uncertain behavior of ovary (236.2) polycystic ovaries (256.4) ovarian endometriosis (617.1) ovarian follicular cyst (620.0) corpus luteum cyst of ovary (620.1) and other and unspecified ovarian cyst (620.2).

Vulvar Biopsy Vulvar biopsy is an office-based procedure that involves taking a sample of an abnormal mole lesion or other dermatosa that does not respond to topical or other conventional treatments. With topical anesthesia the biopsy sample is taken via shaving the lesion excision or puncturing the cyst or lesion and extracting a sample.

The CPT codes for vulva biopsy are 56605* (Biopsy of vulva or perineum [separate procedure]; one lesion) and +56606* ( each separate additional lesion [list separately in addition to code for primary procedure]). Code 56606 is an add-on code and its definition indicates that it can be billed in multiples for every lesion excised after the first one. Consequently if a patient has three separate lesions biopsied the claim form would read line by line:

  • 56605
  • 56606 x 2.

    You should note that there is no modifier listed with 56606. "This is because a CPT 'add-on' code does not require one as it is understood it can only be reported with the primary procedure " Witt says.

    Because the vulva is the external genitalia disorders that prompt a vulvar biopsy are always dermatological or occurring on the surface of the skin. Corresponding ICD-9 codes for vulvar biopsy might be other specified viral warts (078.19); secondary syphilis of skin or mucous membranes (091.3); other specified venereal diseases (099.8); lipoma of other skin and subcutaneous tissue (214.1); benign neoplasm of vulva (221.2); unspecified ulceration of vulva (616.50); other specified inflammatory diseases of cervix vagina and vulva (616.8); endometriosis of pelvic peritoneum (617.3); endometriosis of other specified sites (617.8); dystrophy of vulva (624.0); polyp of labia and vulva (624.6); other specified noninflammatory disorders of vulva and perineum (624.8); pruritus of genital organs (698.1); circumscribed scleroderma (701.0); acquired keratoderma (701.1); acquired acanthosis nigricans (701.2); sebaceous cyst (706.2); other specified disorders of skin (709.8); and embryonic cyst of cervix vagina and external female genitalia (752.41).

    Vaginal Biopsy Vaginal biopsies are called for when an abnormality is found in the vaginal canal. The growth or abnormality either can be sampled or excised depending on its size and nature. Vaginal biopsies generally take place in the office setting and the sample is sent out to pathology for an interpretation. If the biopsy reveals malignancy the patient is scheduled for surgery.

    CPT codes for vaginal biopsy are 57100* (Biopsy of vaginal mucosa; simple [separate procedure]) and 57105 (... extensive requiring suture [including cysts]). Supporting ICD-9 codes for 57100 and 57105 include benign neoplasm of vagina (221.1); cervicitis and endocervicitis (616.0); specified uterovaginal prolapse (618.8); vaginal dysplasia (623.0); vaginal leukoplakia (623.1); vaginal stricture or atresia (623.2); leukorrhea not specified as infective (623.5); vaginal polyp (623.7); other specified noninflammatory vaginal disorders (623.8); other abnormal granulation tissue (701.5); embryonic cyst of cervix vagina and external female genitalia (752.41); and other anomalies of cervix vagina and external female genitalia (752.49).

    Cervical Biopsy Cervical biopsies can be performed with or without colposcopy. When colposcopy is performed the physician inserts a colposcope (a binocular microscope used for direct visualization of the vagina and cervix) into the vagina to examine and excise suspect tissue. The physician then takes one or more samples from the cervix and also occasionally the endocervical canal. When biopsies are performed without a colposcope a speculum is used to visualize the cervix and biopsy forceps are used to remove pieces of tissue or to remove a lesion on the cervix. Fulguration may be required to stop any minimal bleeding following the procedure. "Colposcopic cervical biopsies are the main ones that our practice does " says Penny Schraufnagel CPC office manager at OB-GYN Center PA in Boise Idaho. "We would rarely be doing those without an abnormal Pap smear which would be a clear indication for the colposcopy. Then the results of the colposcopy would show the need for biopsies of suspicious areas."

    CPT codes for cervical biopsy are 57454* (Colposcopy [vaginoscopy]; with biopsy[s] of the cervix and/or endocervical curettage) and 57500* (Biopsy single or multiple or local excision of lesion with or without fulguration [separate procedure]). Possible linking ICD-9 diagnoses for these procedures include viral warts (078.19); malignant neoplasm of exocervix (180.1); malignant neoplasm of other specified sites of cervix (180.8); other benign neoplasm of cervix uteri (219.0); carcinoma in situ of breast and genitourinary system (233.3); cervicitis and endocervicitis (616.0); unspecified inflammatory disease of cervix vagina and vulva (616.9); erosion and ectropion of cervix (622.0); cervical dysplasia (622.1); cervical leukoplakia (622.2); cervical mucous polyp (622.7); other specified noninflammatory cervical disorders (622.8); unspecified noninflammatory cervical disorder (622.9); other abnormal granulation tissue (701.5); nonspecific abnormal Papanicolaou smear of cervix (795.0); nonspecific abnormal Papanicolaou smear of other site (795.1); observation for suspected malignant neoplasm (V71.1); and special screening for malignant cervical neoplasm (V76.2).

    Witt adds that if a payer denies a procedure it may be because the diagnostic code used is not one "on the payer's list" a list that is often unavailable to the provider. These denials should be appealed as long as the physician believes that the biopsy was medically necessary. "Oftentimes " Witt says "a successful appeal is just a question of educating payers and getting them to add a particular diagnosis code to their current edit list."

     

     

     

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