Ob-Gyn Coding Alert

Get to the nitty-gritty of enterocele combos -- and get the payment you deserve

Last month, you learned how to use approach, uterine size/weight and extent to report hysterectomies -- but that's only part of your code selection process. To get these codes right every time, you-ve got to take into account additional procedures your ob-gyn may perform.

Begin With Burch Code Choices

First, when your ob-gyn performs a bladder and/or urethra fixation for stress incontinence in addition to a hysterectomy, you-ve got three coding options. And depending on the fixation point, your physician will refer to this as a -Marshall-Marchetti-Krantz,- -Burch- or -Pereyra- procedure, says Melanie Witt, RN, CPC-OGS, MA, an independent coding consultant in Guadalupita, N.M.

For an abdominal approach, you should use 58152 (Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]; with colpo-urethrocystopexy [e.g., Marshall-Marchetti-Krantz, Burch]).

For a vaginal approach, you-ll use 58267 (Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy [Marshall-Marchetti-Krantz type, Pereyra type] with or without endoscopic control) or 58293 (Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy [Marshall-Marchetti-Krantz type, Pereyra type] with or without endoscopic control). Notice how you-ll choose the correct vaginal approach code based on weight: 250 grams or less, or greater than 250 grams.

Revisit Your Vaginectomy Options

Hysterectomies involving partial or total vaginectomies (colpectomies) have codes of their own.

For example, if your ob-gyn performed an open hysterectomy, you should use 58200 (Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube[s], with or without removal of ovary[s]).

Code 58200 represents removing the uterus as well as neighboring areas (the parametrium and uterosacral ligaments) and includes a partial vaginectomy. Ob-gyns perform this procedure when endometrial cancer has spread to the cervix or parametrium, Witt says.

Keep in mind: Code 58210 (Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling [biopsy], with or without removal of tube[s], with or without removal of ovary[s]) also includes a vaginectomy -- -upper one-third of the vagina, to be exact,- Witt says.

If the ob-gyn performed this via a vaginal approach, you-ll use either 58275 (Vaginal hysterectomy, with total or partial vaginectomy), 58280 (... with repair of enterocele), or 58285 (Vaginal hysterectomy, radical [Schauta type operation]).

Latch Onto These Lymph Scenarios

When an ob-gyn performs a para-aortic and pelvic lymph node sampling, he's performing a lymph node biopsy. He can perform this only via an abdominal approach. For this service, you-ll report 58200. You-ll see this service referred to as a -modified radical- abdominal. This includes a partial vaginectomy.

On the other hand, if your ob-gyn performs a bilateral pelvic lymphadenectomy and para-aortic lymph node sampling, you-ll use 58210 for the abdominal approach.

Evaluate These Enterocele Repair Codes

Enterocele repair combination codes include hysterectomies. For a vaginal approach, you have:

--58263 -- Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele

--58270 -- Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele

--58280 -- Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele

--58292 -- Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele

--58294 -- ... with repair of enterocele.

A vaginal hysterectomy with an abdominal enterocele repair, however, does not have a combination code, but ob-gyns would never do this anyway.

Test What You-ve Learned

Scenario: How should you code a vaginal hysterectomy with a uterus weighing less than 250 grams without the removal of tubes and ovary with enterocele repair and colpourethrocystopexy?

Answer: You have two options.

You-ll report the vaginal hysterectomy with enterocele repair using 58270. You-ll submit the simple anterior vesicourethropexy using 51840 (Anterior vesicourethropexy, or urethropexy [e.g., Marshall-Marchetti-Krantz, Burch]; simple). The National Correct Coding Initiative (NCCI) does not prevent you from reporting this code combination, and you have a better chance of receiving reimbursement with this option.

Alternatively, you could report the vaginal hysterectomy with colpourethropexy with 58267 (Vaginal hysterectomy, for uterus 250 g or less; with colpourethrocystopexy [Marshall-Marchetti-Krantz type, Pereyra type] with or without endoscopic control) and the vaginal enterocele repair as 57268 (Repair of enterocele, vaginal approach [separate procedure]).

According to the Medicare Physician Fee Schedule, the work relative value unit (RVU) for 58270 is 15.20 and 51840 is 11.28. That's a total of 26.48 work RVUs. Your second option's RVUs are as follows: 18.23 work RVUs for 58267 and 7.47 work RVUs for 57268. That's a total of 25.70 work RVUs. Based on these RVUs, you-re better off reporting the first option.

Note: Peggy Stilley, CPC, ACS-OB, OGS, clinic manager at Oklahoma University Physicians in Tulsa, provided this information during her -Gynecology Nuts and Bolts- presentation at The Coding Institute's 2006 National Pediatric and Ob-gyn Coding and Reimbursement Conference. Look for information regarding the 2007 ob-gyn coding conference at www.codingconferences.com.