Ob-Gyn Coding Alert

Editors Note: Experts in ob/gyn coding agree that successful coding in this specialty requires a sound knowledge of medical terminology, the procedures involved and correct codes and coding. Our goal is to present actual coding cases within the context of the medical terminology and procedures. If you have a case youd like to submit for consideration, please send it via fax, email or mail (contact information on page 2.)

A 65-year-old woman presents to her gynecologist with the complaint that everything is falling out. Twenty years ago, the woman had a vaginal hysterectomy and has been problem-free until the emergence of the current problem. Upon examination, the woman is found to have a total prolapse of the vaginal wall and vaginal cuff in clear view at the introitus. Upon further examination, a cystourethrocele and high rectocele are also noted. After discussing the findings with the patient, the ob/gyn schedules surgery to perform a sacrospinous ligament fixation, enterocele repair and anterior and posterior repair. Following the surgery, the coder receives an operative report that describes an anterior/posterior (A&P) repair with enterocele repair along with a sacrospinous ligament fixation.

Terminology and Procedures

A womans reproductive organs are suspended from the pelvic bones by an elaborate structure of muscles, ligaments and connective tissue. With age, the stress of bearing children, previous surgery and other factors, the suspension system weakens. The result is a loss of pelvic support, sometimes called pelvic relaxation. The patient will often present with a feeling of heaviness or fullness in the pelvic region. She may describe her symptoms as something falling out of the vagina. She also may experience incontinence or urine leakage, difficult bowel movements and lower back and abdominal pain.

If the pelvic support continues to weaken, as in this case, one or more of the surrounding organs (bladder, small intestine, rectum or uterus) may protrude or bulge into the vagina. This condition is referred to as vaginal or genital prolapse (ICD-9 codes 618.X). The selection of the fourth digit will depend on which organs or combination of organs are protruding into the vagina. When reviewing these operative reports, the following definitions will be helpful.

Cystourethrocele simultaneous occurrence of a cystocele and urethrocele

Cystocele descent of a portion of the posterior bladder wall and trigone (the small triangular space at the base of the bladder) into the vagina.

Urethrocele sagging of the urethra

Rectocele rectovaginal hernia in which the rectum prolapses into the vaginal canal

High rectocele rectocele that involves the entire posterior vaginal wall

Enterocele herniation of the rectouterine pouch into the rectovaginal septum, which presents as a bulging mass in the posterior fornix and upper posterior vaginal wall

Note: Vaginal vault prolapse following a hysterectomy is the result of an enterocele and demands a different diagnosis code. See box on diagnosis codes below for genital prolapse.

In this case the surgical repair includes an anterior and posterior colporrhaphy with enterocele repair along with a sacrospinous ligament fixation. The sacrospinous ligament fixation is a transvaginal procedure that suspends the vaginal vault to the sacrospinous ligament. The vaginal mucosa is separated from the rectovaginal tissues and the associated enterocele is repaired by suturing the vagina.

Coders Notebook

The following discussion illustrates why a knowledge of the terminology, procedures and codes is critical, not only to correctly code, but also to maximize your reimbursement. Originally the claim was coded as follows:

57282 (sacrospinous ligament fixation)

57268-51 (repair of enterocele, vaginal approach)

57240-51 (anterior
colporrhaphy)

Here, the coder decides to code for both the sacrospinous ligament fixation (57282) and the repair of the enterocele (57268). In addition, the coder assumes that the posterior colporrhaphy is included in the enterocele, and therefore codes only for the anterior colporrhaphy (57240). This is what the insurance carrier did in response to this submission:

57282 19.47 RVU @ $35/RVU = $681.45

57268-51 15.28 RVU (denied)

57240-51 14.35 RVU @ $35/RVU = $502.25 50% discount for second procedure = $251.12

Total allowed: $932.57

Note: The RVUs are based on 1998 RBRVS but the conversion factor of $35 is estimated between the 1998 and 1999 Medicare conversion factors.

The code 57268 was denied as being included in code 57282. The coder failed to use a modifier 59 on code 57268 to indicate that it was distinct from the other procedures (57268 is a CPT separate procedure). Not only was the claim not correctly coded, the coder failed to maximize reimbursement.

The operative report described an anterior/posterior repair with enterocele repair along with sacrospinous ligament fixation. The enterocele repair can be included in the anteroposterior colporrhaphy repair. The correct codes would be to include the A&P repair with enterocele repair (57265) and the sacrospinous ligament fixation (57282). This accounts for all of the procedures performed and avoids the issue of coding for a CPT separate procedure. All services billed would then be reimbursed. Code 57265 (Combined anteroposterior colporrhaphy with enterocele repair) has the higher RVU so it should be listed first. The 51 modifier for multiple procedures performed at the same session would be added to the 57282 (sacropsinous ligament fixation). The 57265 code will be linked to diagnosis codes 618.6 (vaginal enterocele) and 618.0 (cystourethrocele and rectocele). The 57282 will be linked to diagnosis code 618.5 (prolapse of vaginal vault after hysterectomy). Now, look what happens when its coded correctly (increased reimbursement of $208.60):

57265 22.87 RVU @ $35/RVU = $800.45

57282-51 19.47 RVU @ $35/RVU = $681.45 50%
discount for second procedure = $340.72

Total allowed: $1,141.17

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, 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.