Ob-Gyn Coding Alert

Question: I've got the following op note sitting on my desk. My ob-gyn writes: "The patient was taken to the OR where a surgical pause was performed. She was then placed under spinal anesthesia without difficulty. She was prepped and draped in the dorsal lithotomy position. The superior vaginal cuff cyst was excised using a combination of a scalpel and Metzenbaum scissors. The posterior vaginal cuff lesion was taken off similarly. Three biopsies, one at 7 o'clock on the vaginal cuff and one on each lateral side wall approximately one third of the way down, was taken with the Tischler forcep. Hemostasis was achieved with electrocautery." Do you have any advice as to how I should code this?

Hawaii Subscriber

Answer: First, isolate your code choices. You could use 57100 (Biopsy of vaginal mucosa; simple [separate procedure]) as the op note specifically mentions biopsy of sites that are in a different location from the lesions removed. Then, you should report 57135 (Excision of vaginal cyst or tumor) for the excision of the vaginal cuff cysts. The vaginal cuff is what remains after the ob-gyn has removed the cervix and forms the upper boundary of the vaginal canal for patients who have had a hysterectomy.

If you look at the relative value units (RVUs) for these procedures, you'll see that 57100 has 1.2 work RVUs and 57135 has 2.68 work RVUs. Therefore, you should report 57135 first, followed by 51700 to maximize your reimbursement. Be sure to add modifier 59 (Distinct procedural service) to 57100 to reflect this was a distinct procedure. If you failed to append this modifier and provide supporting documentation, your payer would only reimburse 57135 due to correct coding initiative (CCI) edits bundling these codes.