Ob-Gyn Coding Alert

Ob/gyns often perform more than one service or procedure on the same day or during the same global surgical period, and choosing the right modifier can be maddening.

According to CPT: Coders must report the most significant procedure first" with all other procedures listed with modifier -51 appended."

There are certain circumstances when modifier -51 should not be used. For example it should not be used with add-on codes or E/M services. CPT identifies an add-on code with a + symbol and other codes excluded from modifier -51 use with the msymbol. In addition all of these excluded codes are listed in CPT's appendices E and F.

If your ob/gyn performs multiple procedures on the same day at the same session you should report this modifier. "For example when performing multiple ultrasounds our office will use modifier -51 as follows: complete ultrasound (76805) performed with a biophysical profile (76818) reported as 76805 76818-51 " says Brenda Dombkowski CPC Obstetric-Gynecology & Infertility Group Cheshire Ct.

CPT directs that modifier -58 should be used "when a procedure(s) or service is prospectively planned as a staged procedure or when the secondary and subsequent procedure(s) is more extensive or to indicate therapy following a diagnostic surgical procedure " To clarify further modifier -58 should be used if a procedure performed by the same physician during the postoperative period is:

1. Planned prospectively at the time of the original procedure (staged). For instance the patient needs to have tandems and ovoids (57155) inserted and the physician plans to insert them on two separate dates (e.g. two weeks apart). In this case the same code is billed each time but on the second date of service append modifier -58 to 57155.

2. More extensive than the original procedure. Dombkowski offers the following illustration: A physician performs a diagnostic hysteroscopy with a D&C (58558) on a patient with postmenopausal bleeding and an abnormal ultrasound revealing a possible growth. The surgeon does not suspect cancer but the pathology report reveals endometrial carcinoma. The doctor schedules a radical TAH/BSO with bilateral lymphadenectomy (58210) three days later and reports 58558 and 58210-58. If cancer is suspected and the surgeon plans the biopsy as the first step to proceeding to cancer surgery this is also an example that would apply to the first criterion for this code (staged procedure).

3. For therapy following a diagnostic surgical procedure. Dombkowski says that the following situation warrants the use of modifier -58: A physician performs a diagnostic D&C (58120). Pathology reveals CIN III. The doctor then performs a conization of cervix (57520). Report 58120 and 57520-58.

Modifier -59 should only be used when no other modifier applies to services performed by the same physician on the same day and it is used to indicate that a procedure that would normally be bundled with other procedures was distinct during this surgical session. It is primarily used with codes that are designated as "separate procedure" in the CPT book but it may be used in other circumstances as well.

Modifier -59 may be used with the primary procedure if that procedure has the higher RVU. Most often it will be added to a code that is a separate procedure performed for a reason unrelated to the primary procedure. CPT states that this modifier is "appropriate under certain circumstances." They include:

1. A different session or patient encounter. The distinct service is provided during a different patient encounter even though a similar procedure may be performed. "For example a physician performs a D&C (58120) in the morning and the patient continues to bleed  throughout the day and the doctor performs a hystero-scopy D&C that evening (58558). In this case the hysteroscopy procedure has a higher RVU so the code order is 58558 58120. You may append the modifier to either procedure code because neither is listed in CPT as 'separate procedure ' " says Penny Schraufnagel office manager for Ob-Gyn Center PA Boise Idaho.

2. A different procedure or surgery. For example a patient has uterine fibroids and a TAH/BSO (58150) is performed. The patient also had a symptomatic enterocele that was repaired abdominally (57270-59).

3. A different anatomical site or organ system. The patient is having a vulvar lesion biopsied (56605) and at the same session the surgeon removes a 2.0-cm benign cystic lesion on the inside of her thigh (11402). Report 11402 56605-59 for the services.

4. A separate incision/excision. A physician performs a laparoscopy with LSO (left salpingo-oophorectomy 58661) and a laparotomy with RSO (right salpingo-oophorectomy 58720). In this case append modifier -59 to the primary code because it carries greater RVUs and is the code that CPT designates as the "separate procedure." The code order is 58720-59 58661-51.

5. A separate lesion. A patient has an ovarian abscess and an ovarian cyst. The surgeon performs drainage of the ovarian abscess (58820) on the first ovary and then drains the ovarian cyst on the other ovary (58800-59).

6. A separate injury. Use modifier -59 if an injury occurs during a procedure and that injury necessitates another procedure. For example during an abdominal procedure the bladder is inadvertently torn and must be repaired. The surgeon reports the primary procedure with 51860-59 (Cystorrhaphy). Note however that Medicare will not reimburse the surgeon for repairing an inadvertent injury.

During the postoperative period a procedure may be performed that is totally unrelated to the original surgery. Modifier -79 should signal payers that this new procedure is not part of the original period. "For example modifier -79 would be appropriate if a patient had a hysterectomy and then in 90 days the patient developed urinary problems because she strained herself when lifting something that caused a prolapse. This led to the patient requiring a vaginal prolapse repair. In this scenario append modifier -79 to the prolapse repair." Schraufnagel says.