Ob-Gyn Coding Alert

Reader Question:

Vault Suspension

Question: The physician performed a simple vaginal vault suspension at the time of a vaginal hysterectomy. What is the code for this procedure, and can it be charged in addition to vaginal hysterectomy?

Dana Marcos
Accounts/Receivable Coder, Mo.

Answer: A vaginal vault suspension is described by more than one CPT code, depending on the approach and where the suspension was anchored. Code 57280 (colpopexy, abdominal approach) describes a vaginal vault suspension when the physician makes a lower abdominal incision and attaches the vault of the vagina to the prominent point of the sacrum to stabilize the vaginal vault and prevent prolapse of the vagina. This procedure uses surgical fabric or a strip of the internal sacral wall to form a bridge.

A second type of vaginal vault suspension is performed via a transvaginal approach and is called a sacrospinous ligament fixation for prolapse of vagina (57282). In this procedure, the physician makes an incision in the apex of the posterior vaginal wall and enters the space between the rectum and vagina. The prolapsed vaginal vault is then sewn to the internal ligament between the sacrum and the right pelvic bone.

Many insurance companies deny these procedures when billed at the time of vaginal hysterectomy because the physician has failed to indicate a medically necessary reason for the procedure. In other words, the insurance companies are not willing to pay for preventive surgical procedures, only those that correct a problem such as significant vaginal prolapse. Unfortunately, many vaginal vault suspensions are performed to prevent, not correct a problem. You will need to check your physicians documentation to bill the suspension with a vaginal hysterectomy. If you can bill for it, the codes would be reported as 58260 (vaginal hysterectomy) or 58262 (vaginal hysterectomy; with removal of tube[s] and/or ovary[s], and 57280-51 or 57282-51, using the modifier for multiple procedures.)

Although these codes are not listed as bundled procedures in the Medicare Correct Coding Initiative (CCI) when performed with vaginal hysterectomy, code 57280 was identified as one of the secret black box edits late last year. The only way to bypass a Medicare edit when the procedure was performed for a distinct, medically necessary reason would be to add modifier -59 (distinct procedural service) to the bundled code (in this case 57280).
If the procedure was not done because of the documented presence of vaginal prolapse, do not bill Medicare for the service. If, on the other hand, the physician performed a McCalls culdoplasty (i.e., a transvaginal enterocele repair, which is a procedure sometimes done to correct for or prevent vaginal vault prolapse at the time of vaginal hysterectomy), the correct code would be 58263 (vaginal hysterectomy; with removal of tube[s], and/or ovary[s], with repair of enterocele) or code 58270 (vaginal hysterectomy; with repair of enterocele). The enterocele procedure here involves incising and ligating the enterocele sac through a vaginal incision. The physician then approximates the uterosacral ligaments and endopelvic fascia anterior to the rectum.

Source for reader questions: Melanie Witt, RN, CPC, MA, former program manager, department of coding and nomenclature.