Ob-Gyn Coding Alert

Ob/gyns occasionally encounter anatomical irregularities that render a patient infertile or even threaten her life. The extra work and unusual surgical procedures involved present special challenges when reporting diagnosis and treatment of these anomalies. A clear understanding of these irregularities, as well as thorough documentation, is key to proper coding and reimbursement.

Uterine Anomalies

Although uterine anomalies often leave women infertile, those who can become pregnant experience higher than normal incidences of spontaneous abortion, preterm labor, abnormal fetal presentations and other complications leading to perinatal morbidity and mortality. The uterine anomalies reported most often include the following:
 
Double Uterus or Uterus Didelphys. A double cervix and, occasionally, a double vagina characterize this condition. Surgery can restore fertility when a double uterus results in a blocked vagina, cervix or uterus. It poses no risk to pregnancy or reproductive functioning in other patients, although preterm labor and breech positioning are more common in patients with a double uterus. Diagnostic codes include 752.2 (Doubling of uterus) and 654.0x (Congenital abnormalities of uterus). A double vagina, when associated with a doubling of the uterus and cervix, is included in the 752.2 diagnosis code.
 
Bicornuate Uterus and Uterus Unicornis. A single cervix and double uterus (partially fused together) are characteristic of a bicornuate uterus.
 
A single (rather than double) uterine horn in women with uterus unicornis can complicate pregnancy, leading to spontaneous abortion, ectopic pregnancy, abnormal fetal presentations, intrauterine growth restriction and premature labor. The undeveloped "rudimentary horn" may have to be excised to avoid ectopic pregnancy. Patients with uterus unicornis frequently suffer from anomalies of the kidney associated with the malformations.
 
These two conditions share the same diagnosis code: 752.3 (Other anomalies of uterus).
 
Uterine anomalies are not always corrected, particularly if they pose no threat to fertility or if the patient does not wish to become pregnant. When a patient presents to her ob/gyn with one of these conditions, however, it presents some coding and reimbursement challenges.
 
"I had a perimenopausal patient present with menstrual hemorrhaging," says Harry Stuber, MD, a gynecologist based in Cookeville, Tenn. "She informed me that she had two uteruses and two cervixes." Stuber completed a full office visit and examination (she was a new patient, and he documented a comprehensive examination and history with moderate complexity of medical decision-making) and performed two endometrial biopsies (one for each uterus). "I sent separate specimens to the lab," he says, "so I felt justified in billing for two endometrial biopsies with modifier -51 [Multiple procedures]." Since the second uterus is considered a second organ, modifier -59 (Distinct procedural service) can also be appended to the biopsy code.
 
The encounter is coded 99204 (Office or other outpatient visit for the evaluation and management of a new patient ) appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), 58100* (Endometrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, any method [separate procedure]), and 58100* appended with modifiers -51 and -59.
 
Diagnosis code 626.2 (Excessive or frequent menstruation) would be linked to 99204, while 752.2 would be linked to the biopsy codes.
 
The physician should document the presence of the second uterus. Although some payers may reduce the allowable on the second biopsy (usually by 50 percent), some may pay in full for both procedures because the procedure involves two separate organs. In any event, the physician would bill his or her full fee for both.

Oversized Growths

Some patients have tumors or cysts of unusual proportions. Stuber recalls a patient (65 years old and non-Medicare) who was referred by her primary care physician (PCP) with an approximately 1-pound tumor on the exterior of her vulva. At the initial encounter Stuber excised the tumor, which came back from the lab with a diagnosis of fibroma.
  
The patient continued to receive care from Stuber. A Pap smear was returned with a diagnosis of atypical glandular cells of undetermined significance (AGUS) after her annual exam.
 
"Although the patient showed no hormonal abnormalities or bleeding, I performed an endometrial biopsy just to be on the safe side," he says. The biopsy revealed endometrial carcinoma, after which Stuber performed a total abdominal hysterectomy and bilateral salpingo-oophorectomy.
 
The location and size of the tumor were unusual; even so, the case is fairly straightforward from a coding perspective. First and foremost, the patient was a referral from a PCP for treatment, and her care involved an E/M visit and an excision. The initial encounter is coded 99204-25.
 
This level of new patient E/M may even be a 99205, if medical decision-making has been documented as highly complex when combined with a comprehensive history and examination. This might include noting that the new problem will involve further workup and that the patient is at high risk owing to this chronic condition posing a threat to life.
 
Or perhaps the data reviewed were extensive (remember that the level of medical decision-making is based on two of the three elements of the number of diagnostic/treatment options, amount and complexity of data reviewed, and risk of morbidity/mortality).
 
Code 56620 (Vulvectomy simple; partial) is appropriate if the procedure is billed prior to receiving the pathology report. If removal required additional time or effort on the surgeon's part, modifier -22 (Unusual procedural services) can be appended to this excision code. An accompanying letter from the surgeon should indicate the highly unusual nature of the tumor, the degree of difficulty above what is considered normal for 56620, and a specific request for additional reimbursement equal to what the surgeon feels is fair for the time and effort involved.
 
Stuber's other option is to code the surgery 11426 (Excision, benign lesion, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm). CPT notes that modifier -22 should be appended to this code for unusual or complicated excision.
 
The diagnostic code for the initial problem-oriented visit depends on when the service is billed. The physician knows the patient has a growth on the vulva, but does not have the pathology result until a few days later. If he or she bills the service before getting the pathology report, the only code that is accurate for both the E/M service and the excision is 239.5 (Neoplasms of unspecified nature; other genitourinary organs). If billing for the service takes place after the pathology report has been received, 239.5 is linked to the E/M code (because this is why she was seen) and 221.2 (Benign neoplasm of other female genital organs; vulva) is linked to the excision code.
 
Stuber's follow-up care with this patient for her annual a year later is coded 99397 (Periodic comprehensive preventive medicine reevaluation and management of an individual ).
 
When the Pap smear returned with an AGUS result, the encounter for the endometrial biopsy (58100*) would be linked to 795.0 (Nonspecific abnormal Papanicolaou smear of cervix) and the subsequent surgery to 182.0 (Malignant neoplasm of the corpus uteri, except isthmus). If the procedure was an abdominal hysterectomy without lymph node sampling, the procedure code would be 58150.
 
Although a physician may feel that he or she has taken more than a "normal" amount of time and effort to excise a large cyst, carriers do not always see it that way. Tori Heckart, insurance specialist with Ottumwa Ob/Gyn in Ottumwa, Iowa, recounts a case where the practice had tremendous difficulty in obtaining additional payment. A 20-year-old patient presented with a complaint of painful menstruation (625.3) that had persisted for several years.
 
The physician examined her and found a large abdominal mass that had caused the abdomen to distend. An ultrasound confirmed the presence of the mass, and a confirmatory ultrasound showed that the mass filled the entire pelvis and abdomen. The physician scheduled a laparotomy and, according to his note, "a probable unilateral salpingo-oophorectomy."
 
Heckart explains that the surgery was extremely complicated due to the uncertain nature of the mass and its size (42 cm). Because of the suspected malignancy and the risk of spreading carcinoma cells into the abdominal cavity, the surgeon opted to remove the mass entirely rather than drain it then remove it.
 
The ob/gyn performed a laparotomy, right para-ovarian cystectomy, partial right salpingectomy and an appendectomy. Heckart coded the surgery 58925 (Ovarian cystectomy, unilateral or bilateral), appended with modifier -22 for the removal of a serous cyst (620.2).
 
"There's not really another code to fit the procedure," she explains, "since the cyst was removed and not drained." Although the cyst was biopsied, this service is included in the cystectomy code. The surgery was major but not as radical as the surgeon initially thought it might be since no malignancy was found.
 
There is still some controversy over coding for an appendectomy when the reason for removing the appendix is not clear from the documentation. In this case, the pathology report showed a normal appendix; if this procedure is to be coded, the initial reason for its removal must be indicated on the claim.
 
Heckart reported difficulty in getting reimbursed for the surgery, and ultimately recouped just less than half of the surgeon's and assistant surgeon's fees. "We sent all the records each time we refiled," she says, "and the surgeon even dictated additional notes for payment."
 
Heckart's difficulties illustrate the problem when a code for a seemingly routine surgery doesn't jibe with the surgery performed. Her coding was correct, but the carrier still refused to pay a reasonable amount for the procedure. Coding right the first time is the first step in reimbursement. For surgeries such as the one described here, where coders can anticipate reimbursement problems, make sure that the initial documentation includes detailed information as to the length of time for the removal of the cyst, additional suturing, risk of complications during surgery, etc. A peer review of the documentation submitted might also reveal areas where the argument for reimbursement can be strengthened.