Ob-Gyn Coding Alert

Editors Note: The following case comes from several members of our Editorial Advisory Board (see listing of Board on back page). It is the presentation of an actual case in which a review of the coders first claim was found to be both incorrect and did not maximize reimbursement. We will present both the correct and incorrect coding of this case. This should help illustrate several important points in coding complex gynecological operative reports and maximizing reimbursement for these surgeries.

The billing department at a busy ob/gyn practice receives an operative report for a 72-year-old patient who had been referred to the practice by her primary physician with problems of incontinence. After several office visits with extensive physical examination and urodynamic testing the patient was scheduled for surgery. The operative report contains the following preoperative diagnoses: intrinsic sphincter deficiency (ISD) with urinary incontinence, pelvic prolapse, complete vaginal vault prolapse, cystocele, rectocele, enterocele. Additionally, buried in the body of the operative report is the diagnosis of stress incontinence.

Also, in the operative report, the physician describes the following procedures being performed:

Sling urethropexy using patch of rectus fascia

Anterior and posterior repair

Enterocele repair

McCalls culdoplasty

Iliococcygeal vaginal vault suspension

Perineorrhaphy

Cystoscopy

Suprapubic catheter placement

Understanding the Terminology and Procedures

An understanding of the terminology and procedures is particularly important to the correct coding of this case.

1. Terminology:

The womans incontinence is related to multiple problems in her abdomen and pelvic region. Weakness in the vagina walls has allowed for protrusion or herniation through the vaginal wall of the bladder (cystocele), the intestines (enterocele) and the rectum (rectocele). The structures and organs of the pelvic region are supported and held in place (especially during increased intra-abdominal pressure such as when coughing) by a system of muscles, ligaments and fascia. The excessive tearing and trauma to these supporting structures during vaginal delivery can later lead to the prolapse, or falling of these structures referred to as vaginal vault prolapse and pelvic prolapse. The prolapse changes the anatomic support for the bladder and urethra and leads to urinary incontinence.

Traditionally, urodynamic evaluations have been used to differentiate between genuine stress incontinence and other types of incontinence. The Agency for Health Care Policy and Research of the United States Department of Health and Human Services has classified genuine stress incontinence into two subtypes. The first, anatomic stress incontinence (625.6), is attributed to loss of support of the urethrovesicle junction resulting in the descent of the proximal urethra outside the sphere of abdominal pressure transmission during rises in intra-abdominal pressure. The other, intrinsic sphincter deficiency (ISD) (599.82), is attributed to poor urethral sphincter function and is commonly associated with multiple anti-incontinence procedures, menopause, or urogenital atrophy.

2. Procedures:

The sling urethropexy using a patch of rectus fascia (57288) is a fixation or stabilization of the urethra with a sling made by using a strong piece of fascia (covering of the muscle) harvested from the lower leaf of the rectus fascia or the outer aspect of the thigh. Using incisions in the abdomen and vagina the sling provides support by being sewn into place. The anterior and posterior repair refers to the performance of an anterior and posterior colporrhaphy, which is the use of sutures to repair of the cystocele (anterior), the rectocele (posterior) and in this case, the enterocele (57265). The McCall culdoplasty, entails suspension of the posterior fornix of the vagina and repair of enterocele by attaching the vaginal apex to transverse sutures placed across the rectouterine pouch. It is a transvaginal procedure and can either be done to prevent an enterocele or to repair one that has developed. When done prophylactically insurers frequently deny the claim. It is a transvaginal procedure. The Perineorrhaphy is a surgical repair of a rectocele or perineal laceration. In this case the operative report lists the enterocele repair, the A&P repair, the McCall culdoplasty, and the perineorrhaphy, as separate procedures but they are actually bundled together (57265).

The Iliococcygeal vaginal vault suspension (57282) uses the iliococcygeal muscle as an anchor point, but is just like sacrospinous ligament fixation excepting you are attaching to the iliococcygeal muscle. In this case, because the bladder sphincter needs time to heal, a catheter to drain urine is inserted into the bladder through an incision above the pubic bone and the procedure is called a suprapubic catheter placement (51010). The cystoscopy (52000) is an internal examination of the bladder using an instrument (cystoscope) inserted through the urethra.

Coding Review and Correction

The six points below analyze how original claim was coded and what improvements were made in the Coders Note Book box (shown in the previous column) to maximize its reimbursement:

1) The first problem is in the order of listed diagnostic codes. An important rule for coding multiple diagnoses for multiple procedures is, the primary diagnosis needs to match the primary reason for doing the primary procedure. In this case the primary reason for the surgery is the patients incontinence from the bladder sphincter deficiency and the primary procedure to address that problem is the sling urethropexy (57288).

2) The modifier -52 is incorrectly used with the anteroposterior colporrhaphy. The service provided here is not reduced or modified even though other procedures are being performed in the same area. The correct modifier is -51 for multiple procedures.

3) The operative report lists the vaginal vault prolapse and pelvic prolapse separately but they are synonymous for coding purposes. But it is important to note that the code reported depends on the presence of the uterus (i.e. 618.0 vs. 618.5). In this case, the operative report implied the uterus was not present.

4) In the operative report the physician describes the vaginal vault repair as an iliococcygeal vaginal vault suspension which presents a problem because there is no direct CPT code for the procedure. The most similar CPT code for describing this procedure is the sacrospinous ligament fixation (57282).

5) The suprapubic catheter insertion is not coded in the original claim. This procedure is not included in any of the procedures reported and can be claimed using 51010. If documented on the report, a possible diagnosis code that could be linked to this procedure would be 788.21, incomplete bladder emptying.

6) The cystoscopy appears on the list of procedures and is coded in the original claim but is not medically justified in the diagnosis list. There must be a medically justified reason for performing the cystoscopy. If a diagnosis is not found, it cannot be coded. Using the cysto to simply check to make sure there are no sutures in the bladder is not enough. Bleeding, distention or some other problem would justify the procedure. Code 52000 is a CPT separate procedure so needs a modifier -59 if they want to claim it is a distinct procedure

Article contributors: Expert advice for this case study was provide buy the following sources: Melanie Witt, RN, CPC, MA, program manager, department of coding and nomenclature, American College of Obstetricians and Gynecologists, Washington, DC; Evelyn M. Gross, CMM, CPC, NR-CMA, Healthcare Specialist, E.M. Gross and Associates, South Amboy, New Jersey; Thomas Kent, CMM, Principal, Kent Medical Management, Dunkirk, MD; Dunnihoo, DR Fundamentals of Gynecology and Obstetrics. J.B. Lippincott and Co.: Philadelphia: 1990.