Ob-Gyn Coding Alert

Getting Paid When Technology Is Ahead of Coding:

Thermal Balloon Ablation

Until recently, most ob/gyns treated dysfunctional uterine bleeding (DUB) with hysteroscopic endometrial ablation. But in December 1997, the Food and Drug Administration (FDA) approved the use of a thermal device designed to ablate the endometrium using a balloon that is inserted into the uterus with a catheter. The balloon is filled with heated water, which has the same effect on the tissue as surgical ablation. This alternative therapy is known as uterine balloon therapy (UBT).

The problem for ob/gyn coders is that the CPT has not yet caught up with the latest technology, and there is currently no CPT code that precisely defines UBT. The American College of Obstetricians and Gynecologists (ACOG) has requested a code for this service, but that request may not be approved for quite some time. What should coders do in the meantime? Can you use 56356 for hysteroscopy and endometrial ablation, as you would for a surgical endometrial ablation? How does thermal ablation differ? Do these differences require a modifier? Can you code for the thermal balloon itself? The answers to these and other questions are quite logical once you fully understand dysfunctional uterine bleeding and uterine balloon therapy as a treatment for certain patients.

What is Dysfunctional Uterine Bleeding?

Dysfunctional uterine bleeding, also known as menorrhagia, is the formal name for prolonged or excessive menstrual bleeding. Current ICD-9 codes associated with this condition are 626.2 (excessive or frequent menstruation), 626.4 (irregular menstrual cycle), 626.6 (menorrhagia), 626.8 (other) and 626.9 (unspecified).

There are many possible causes of this condition, including a hormonal imbalance, abnormal ovulation, uterine trauma, polyps, fibroid tumors, cancer, cervicitis and other infectious conditions. It also can be caused by irritation from an intrauterine device, or it may be a sign of an ectopic pregnancy.

Thermal ablation is not the recommended therapy for all types of DUB. It is not an appropriate therapy when the etiology includes cervicitis, vaginitis, endometriosis, salpingitis, cystitis, fibroids, myomas, unresolved hyperplasia, endometrial carcinoma and other adnexal pathologies. Thermal ablation is contraindicated for patients who have a weakness of the myometrium, an abnormally shaped uterine cavity, an IUD in place, an active genital-urinary infection, sensitivity to latex or a desire to become pregnant.

What is Uterine Balloon Therapy?

Uterine balloon therapy is a technique for ablating the endometrium in patients who have menorrhagia attributed to benign causes and who do not wish to become pregnant. Like surgical ablation using an electrode loop, rollerball or laser, UBT destroys the endometrial uterine lining so that it can no longer grow and shed through menstruation. With the elimination of the endometrium, most patients will become infertile, although UBT is not considered a form of birth control.

The only FDA approved uterine balloon therapy on the market at this time is called the ThermaChoice Uterine Balloon Therapy System. It consists of a single-use balloon catheter, a reusable controller, umbilical cable and power cord. The balloon is attached to the end of the plastic catheter, which is inserted through the vagina into the uterus. Once in place, the balloon is inflated with 5 percent dextrose in water to a pressure of 160-180 mm Hg. The solution also is heated to 87 degrees C. Pressure and temperature are controlled externally.

The balloon is left in place for up to eight minutes in order to coagulate the endometrium to a depth of about 5 mm. The device is then removed, and the patient is observed briefly prior to being sent home. Ob/gyns report a wide range of anesthetic from a general (when the procedure is performed in a hospital) to IV sedation to a paracervical block. George A. Vilos, MD, associate professor of obstetrics and gynecology at the University of Western Ontario, says that the procedure is as simple as inserting an IUD. I have done three patients with no anesthesia, not even a local anesthetic, he explains. What that means is that we can take these patients out of the operating room and do (the procedure) in the office. And thats when we need to know how to code for it.

Optimally Coding for UBT

Since there is no current CPT code for UBT, most ob/gyn coders are reporting the procedure using the hysteroscopy code (56356). But unlike surgical ablation, UBT does not require the use of a hysteroscope at the time of the procedure. A hysteroscopy may be performed diagnostically prior to deciding to perform the UBT, but it is not part of the UBT procedure.

Because thermal ablation does not normally involve hysteroscopy, CPT code 56356 does not adequately describe the procedure, says Larry P. Griffin, MD, the ACOG representative who petitioned the AMA for the coding change.

Due to the lack of other options, practices are using the hysteroscopy code and being reimbursed for UBT. Joan Dent, accounts supervisor for Turning Pointe Womens Health Professionals in Akron, says, We are using the 56356 and havent really had any problems getting paid. However, Dent says they are only performing UBTs within the hospital setting, and not attempting to be reimbursed for the expensive balloon itself (see section below).

An adjustment of 56356 using a 52 modifier is another way to code for UBT, Griffin says, because the modifier notes a reduction in services (i.e. without the hysteroscopy). Also, ob/gyn coders may want to try using 58999 (unlisted procedure, female genital system non-obstetrical). However, Griffin cautions, Because these codes are subject to carrier review, additional documentation, such as operative notes, progress reports and consultation reports, will probably be required before the claim is considered for payment.

Coding to Get Paid for the Balloon

The single-use balloon catheter costs about $700, and ob/gyn coders must be sure to supplement their submissions using code 99070 (supplies and materials over and above those not usually included with services rendered). According to Dent, this is where some practices may begin to have problems performing UBTs in their offices. Checking with your insurance carriers prior to providing the service may help avoid having to seek payment from a patient for the expensive supplies.