Ob-Gyn Coding Alert

"Editors Note: Correctly coding surgical procedures that can pass any audit and also provide maximum reimbursement often turns on the subtle communication between physician and coder through the surgical report. Our goal in these case presentations is to assist coders and ob/gyn practices to excel in understanding the intricacies of ob/gyn coding by examining real coding situations. If you have a case youd like to submit for consideration, please send it to the Editor of OCA via fax, email or mail.

A 42-year-old woman presents to her gynecologist complaining of vaginal pain. The patient is gravid 2, para 2, and eight years ago she experienced a vaginal vault prolapse that was successfully repaired with a suspension procedure that used a Gore-Tex graft. The patient has been in good health except for the recent onset of vaginal pain. Following the gathering of a detailed history, an office examination shows a dimple in the area of the vaginal apex with some vaginal granulation tissue in the area. Because the area is extremely painful and visualization poor, the physician and patient make the decision to proceed to surgery to perform an exam under anesthesia. Depending on what the physician finds, the surgery may also include the removal of the graft or some other more conservative approach. The preoperative diagnosis is vaginal granulation tissue secondary to foreign body.

The patient is taken to surgery and examined under general anesthesia. She is found to have a vaginal defect or fistula located in the vaginal apex. Using cautery, the physician excises the granulated tissue around the fistula and then closes the fistula with sutures.

Terminology and Procedures

The history of this patient explains that she has been pregnant (gravid) twice and delivered (para) 2 viable infants (weighing more than 500 grams). It also explains that she has had a vaginal vault prolapse, which is a weakening of the support of the vagina due to the stress of bearing children, age or previous surgeries. The prolapse allows for the protrusion of one or more surrounding organs (see full description of cystocele, cystourethrocele, urethrocele, rectocele, and enterocele in January 1999 Ob-Gyn Coding Alert, page 7). The old repair of this patients vaginal vault prolapse included a suspension procedure that included the placement of a synthetic graft made from a product called Gore-Tex. The placement of this graft requires an incision into the vaginal wall, which is closed around the graft to maintain the integrity of the vagina. Occasionally, granulation tissue (rough or grain-like tissue) forms around the graft site and may indicate a problem.

The surgical examination involved a careful look at the entire vaginal canal including the apex (the far end of the vaginal canal) where the graft and the granulated tissue had be seen. A small fistula tract, or opening, is found in this area. In this case, the fistula is between the vagina and the surgical graft and is surrounded by granulated tissue. The surgeon repairs the fistula using cauterization (a means of destroying by burning small amounts of tissue with electricity) to remove the granulated tissue around this fistula and then suturing the fistula closed. The graft is left in place.

Coders Notebook

The information provided by the surgeon in her operative report to the coder states that the pre- and postoperative diagnosis are the same: vaginal granulation tissue secondary to foreign body, and the procedures are listed as: examined under anesthesia and cautery of fistula tract and closure of vaginal defect.

From a coding perspective, this information does not reflect the full picture and leaves in doubt correct coding for this claim. It also teaches us that clear communication is always essential. Heres why.

First, from a diagnostic perspective, the surgeon indicated the same diagnosis preoperatively and postoperatively. Unfortunately, there is no code for vaginal granulation tissue, only granulation tissue of the skin (701.5). There is a code for a mechanical complication of a graft, so the code 996.39 could be reported. The surgeon did identify, however, a small fistula located in the vaginal apex during the surgical exam and this would be coded as 619.8. This information should have been included in the operative summary as part of the postoperative diagnosis.

Second, although a fistula tract was located in the vaginal apex, the work involved in repairing it is not described in the existing CPT codes that describe fistula repair. A fistula is a fissure or passage between two cavities. The CPT codes that describe fistula repair include rectovaginal (abnormal passage between the rectum and vagina), urethrovaginal (abnormal passage between the urethra and vagina) and vesicovaginal (abnormal passage between the bladder and vagina). The fistula described in this case is a fissure between the vagina and a surgical graft from a previous surgery, so none of the existing codes would correctly describe the reason the surgery was performed. In addition, a repair of any of the above types of fistulas involves excision of the fistula and surrounding tissues and may also include the use of catheters and, in some cases, grafts. The surgery described by this surgeon, on the other hand, includes cautery of the fistula rather than excision and removing only 1 cm of vaginal mucosa around the opening of the fistula and then over sewing the area.

CPT instructs a coder to select the most substantially correct code but in this case no code exactly matches the procedure. Therefore, one coding option may be 57200 (repair of an injury of the vagina), but as this code only describes wound closure, a modifier 22 (unusual procedural services) may be warranted. Alternatively, the code 58999 for an unlisted procedure may be reported instead. In either case, a copy of the operative report should be submitted with the claim in support of either additional reimbursement for 57200 or to describe the unlisted procedure.

The two alternatives would appear as follows.

Diagnosis Codes:

1) 619.8

2) 996.39

Alternative 1

57200-22 1, 2

Alternative 2

58999 1, 2

Note: Both of the diagnosis codes are designated as nonspecific in the ICD-9, but in this case, neither of these code is unspecified and they are the only ones that fit the case. Since you would be sending in documentation anyway with the claim, these codes should not create a problem.

Article Contributors: Expert advice for this case study was provided by 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 Consultant-Accounting Firm Amper, Politziner & Mattia, NJ; Thomas Kent, CMM, Principal, Kent Medical Management, Dunkirk, MD; Dunnihoo, DR Fundamentals of Gynecology and Obstetrics. J.B. Lippincott and Co.: Philadelphia: 1990."