Ob-Gyn Coding Alert

Find out what your fibroid diagnosis options are for both ICD-9 and ICD-10.

If you're reporting uterine fibroid removal, you need to know two things:

• Where the fibroid was located, so you can choose the diagnosis code.
• What method the ob-gyn used to take care of the growth.

Simplify this complicated coding scenario by busting the following four myths.You'll know where to look in both your ICD and CPT manuals before the fibroid report lands on your desk.

Don't Confuse Fibroids With Polyps

Myth: Fibroids and polyps are essentially the same thing.

Reality: True, fibroids and polyps are both growths, but one occurs in the endometrial lining while the other occurs in the muscle.

Polyps are small growths on the surface of the uterine wall that are easy for the ob-gyn to remove. In other words, "they are an overgrowth of the endometrial lining," says David Glassman, DO, FACOG, medical director of Biltmore Women's Health and Aesthetics and assistant program director at the department of obstetrics and gynecology residency at Banner Good Samaritan in Phoenix. "They're intracavitary lesions."

Fibroids (or myomas) are larger and are usually imbedded in the smooth muscle of the uterine wall. "They are almost always benign, but in rare circumstances, they can become a sarcoma (muscle cancer)," Glassman says. These growths require more work to remove, hence the procedures associated with fibroids tend to have more relative value units (RVUs). They occur in three main locations:

Submucous fibroids (218.0) grow from the uterine wall toward the uterine cavity. They are also called intracavitary fibroids.

Intramural fibroids (218.1) also called interstitial fibroids grow within the uterine wall (myometrium).

ubserous fibroids (218.2) or subperitoneal fibroids grow outward from the uterine wall toward the abdominal cavity.

If the physician does not specify the location of the uterine fibroid, assign 218.9 (Leiomyoma of uterus, unspecified) as the diagnosis.

Important: You should report these 218 fibroid codes based on size, location (the fourth digit), and number, Glassman says.

Sometimes, ob-gyns may have trouble distinguishing between a small fibroid and a large polyp, but "they do have different appearances and textures when visualized during the procedure," Glassman says. If you don't have enough to choose your ICD-9 code, you may need to wait for the pathology to return for a final diagnosis (a delay of 10 days or so).

Look ahead: Once payers start requiring ICD-10, your diagnosis codes will include numbers and letters. For example, ICD-10 2010 lists the previously mentioned fibroid codes as:

D25.0 -- Submucous leiomyoma of uterus

D25.1 -- Intramural leiomyoma of uterus or Interstitial leiomyoma of uterus

D25.2 - Subserosal leiomyoma of uterus or Subperitoneal leiomyoma of uterus

D25.9 -- Leiomyoma of uterus, unspecified

Head to www.cdc.gov/nchs/icd/icd10cm.htm#10updateto learn more about ICD-10.

Examine Your Hysterectomy Options

Myth: If your ob-gyn removes a fibroid and the uterus

entirely, then you should report both procedures.

Reality: You would not code the fibroid removal

separately if the ob-gyn is removing the uterus.

In other words, if the ob-gyn removes the uterus

entirely, he performed a hysterectomy. In the process, he

removed the accompanying fibroids attached to or inside

the uterus.

Hysterectomy is the most common surgical treatment

option, but only when the fibroids are causing problems,

such as abdominal pain or heavy bleeding. Without

removal of the uterus, recurrence of fibroids is common.

The code assignment will depend on the type and extent of

the hysterectomy, says Melanie Witt, RN, COBGC, MA,

an independent coding consultant in Guadalupita, N.M.

For more information on this topic, register for her June 30

presentation at www.audioeducator.com.

Example: Because the patient is older than 50 years

and has multiple fibroids, your ob-gyn performs a total

abdominal hysterectomy (58150, Total abdominal hysterectomy

[corpus and cervix], with or without removal of

tube[s], with or without removal of ovary[s]). You would

not report an additional code for the fibroid removal.

Hem in Your Hysteroscopy Choices

Myth: Your ob-gyn won't treat fibroids via a hysteroscopy.

Reality: An ob-gyn may treat a patient with fibroids

with a hysteroscopy. Hysteroscopic submucous resection

removes a portion of the protruding fibroid and preserves

fertility.

The hysteroscopic procedure requires "the close

monitoring of distention media, electrosurgical devices,

as well as a patient's anatomy to avoid perforating the

uterus," Glassman says. "Ob-gyns usually perform this

straightforward approach for intracavitary (submucosal)

fibroids."

Example: Your ob-gyn removed polyps and fibroids

by hysteroscope. The pathology diagnosis is fibroid. You

should report 58561 (Hysteroscopy, surgical; with removal

of leiomyomata) ��" unless the ob-gyn also performed a

dilation and curettage (D&C). If the ob-gyn did, you can

bill both 58561 and 58558 (Hysteroscopy, surgical; with

sampling [biopsy] of endometrium and/or polypectomy,

with or without D&C).

Master Myomectomy Codes

Myth: A myomectomy means the ob-gyn takes more

than just the uterine fibroids.

Reality: Actually, a myomectomy (58140-58146)

means the ob-gyn removes the uterine fibroids only, which

preserves fertility.

Example: The ob-gyn sees a 32-year-old patient who

has never had a child but would like to. She complains of

heavy menses with anemia. On examination, the physician

finds a 15-week uterus with multiple fibroids that distort

the endometrium. Because the patient wishes to have

children, she elects to have a myomectomy, which the obgyn

performs using an abdominal approach. The pathology

report shows six intramural myomas.

For this case, you should report 58146 (Myomectomy,

excision of fibroid tumor[s] of uterus, 5 or more

intramural myomas and/or intramural myomas with total

weight greater than 250 grams, abdominal approach) with

218.1, says Cheryl Ortenzi, CPC, billing and compliance

manager for BUOB/Gyn in Boston.

Make Use of UAE Option

Myth: Your ob-gyn can treat uterine fibroids only with

a hysterectomy, hysteroscopy, or myomectomy.

Reality: You may see the ob-gyn perform uterine

fibroid embolization or uterine artery embolization (UAE)

procedures. This is a nonsurgical, minimally invasive

procedure that will shrink the fibroids by cutting off the

blood supply.

The ob-gyn inserts a catheter through an artery in the

leg to the arteries in the uterus. The physician then inserts

tiny particles of plastic or gelatin through the arteries to

block the blood flow inside the fibroids. Without blood

flow, the fibroids shrink or may even disappear over time.

You'll report this service using 37210 (Uterine fibroid

embolization [UFE, embolization of the uterine arteries

to treat uterine fibroids, leiomyomata], percutaneous

approach inclusive of vascular access, vessel selection,

embolization, and all radiological supervision and

interpretation, intraprocedural roadmapping, and image

guidance necessary to complete the procedure).