Coding for Urogynecological Surgeries Demands Precise CPT Terminology, Documentation
Urogynecological procedures are performed often in response to complications following total hysterectomies and other gynecological surgeries. Consider the following when billing for these procedures:
- One surgery can have two or more names. For example, a vaginal vault suspension can be a uterosacral ligament vaginal vault suspension, a sacrospinous ligament suspension, or an abdominal sacral colpopexy. CPT has several codes for this type of procedure.
- There are a number of surgical approaches to the same procedure. Harry Stuber, MD, a gynecologist based in Cookeville, Tenn., elaborates: Basically” every urogynecological procedure is done through one or more of three possible routes: abdominal (open) vaginal or laparoscopic.”
- CPT cannot keep up with rapidly changing surgical techniques. ” CPT codes fall short of meeting the needs of innovative surgeons who are developing new approaches practically every day ” Stuber notes.
- CPT advises against picking a code that merely approximates the procedure. “In the current atmosphere of false-claims awareness be sure to select the correct code and not just something similar ” says Jan Rasmussen CPC president of Professional Coding Solutions a medical coding and compliance company in Eau Claire Wis. Rasmussen points to new language in the introduction of CPT 2002 that reads “Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists then report the service using the appropriate unlisted procedure or service code.”
Despite the many ins and outs of coding for urogynecological procedures CPT 2002 provides the tools necessary to bill ethically and accurately for these complicated and costly surgeries.
Vaginal Vault Suspension
Vaginal vault suspension corrects vaginal prolapse following a hysterectomy (the “vault” being the space that the uterus once occupied) when the top of the vagina breaks away from the uterosacral ligaments that once held it in place. If the uterosacral ligaments are not reattached to the vagina during the initial hysterectomy or if they become unattached prolapse can occur.
Note: Cystocele and rectocele refer to anterior and posterior vaginal prolapse respectively and can occur prior to a hysterectomy.
The anchor’s location determines coding for the vaginal vault suspension. If the physician uses an abdominal approach and attaches the vault of the vagina to the sacrum the procedure is called a colpopexy (57280 Colpopexy abdominal approach). Another type of vaginal vault suspension uses a transvaginal approach. An incision is made in the apex or top of the posterior of the vaginal wall and the prolapsed vaginal vault is then sewn to the internal ligament between the sacrum and the right or left pelvic bone. This is coded as 57282 (Sacrospinous ligament fixation for prolapse of vagina). The third type of vaginal vault suspension is a laparoscopic uterosacral ligament suspension in which the uterosacral ligament is attached to the apex of the vagina. Different from a traditional colpopexy because of the laparoscopic approach this procedure does not have a specific CPT code. Report unlisted-procedure code 49329 (Unlisted laparoscopy procedure abdomen peritoneum and omentum). Thorough documentation must be sent with the claim that details the procedure performed and how it is similar to and differs from a related CPT code.
Physicians often run into difficulty when billing these procedures at the same time as a hysterectomy. Although the Ob-Gyn Coding Manual of the American College of Obstetricians and Gynecologists (ACOG) indicates that in the case of total or subtotal abdominal hysterectomies “repair or suspension procedure of vagina urethra and perineum” are “examples of intraoperative services excluded from the global service ” many carriers will cite lack of medical necessity as reason for denying additional charges. This is due primarily to the vaginal vault suspension (at the time of hysterectomy) being a preventive rather than restorative procedure. The surgeon is performing the suspension not because vaginal prolapse has occurred but to prevent it from happening in the future. For non-Medicare carriers the suspension procedure is billed in addition to the code for the hysterectomy (e.g. 58150 Total abdominal hysterectomy [corpus and cervix] with or without removal of tube[s] with or without removal of ovary[s]). The vaginal vault suspension is billed with the appropriate code (e.g. 57280) with modifier -51 (Multiple procedures) appended. Since 57282 includes “for prolapse of vagina” in its descriptor it would not be used at the time of a hysterectomy unless vaginal prolapse occurs. And since there is no diagnostic code for “prevention of vaginal prolapse ” documentation should include the surgeon’s note as to why he or she opted to perform the vault suspension and statistical material supporting vaginal vault suspension at the time of hysterectomy to stave off vaginal prolapse.
For Medicare patients if a vaginal vault suspension is performed without a diagnosis of genital prolapse (618.x series) Medicare will not pay for the additional procedure at the time of hysterectomy. For vaginal vault suspensions that take place with a diagnosis of genital prolapse reimbursement is more consistent as long as the diagnostic code links to the procedure performed.
Patients who require a vaginal vault suspension after a hysterectomy often require other reconstructive supportive procedures such as paravaginal repair enterocele repair posterior repair or Burch urethropexy. Paravaginal repair is required when the bladder and the urethra fall away from the ligaments under the pubic bone. The condition known as cystocele or “bladder drop ” causes urinary incontinence and can cause vaginal prolapse. The repair is accomplished by reconnecting the anterior vaginal wall back to its original point of attachment in the pelvis thus restoring the bladder and urethra to their natural anatomical positions. The repair is coded 57284 (Paravaginal defect repair [including repair of cystocele stress urinary incontinence and/or incomplete vaginal prolapse). This code can be reported in addition to the code for the sacrospinous ligament fixation (e.g. 57282). Since the paravaginal repair has a higher relative value unit (RVU) 57284 should be coded first and modifier -51 appended to 57282.
But there may be more repairs necessary to restore the patient to full urinary function or anatomical normalcy. A Moschowitz or Halban enterocele repair (57270 Repair of enterocele abdominal approach [separate procedure]) or a McCall’s enterocele repair (57268 Repair of enterocele vaginal approach [separate procedure]) is used to close a defect between the uterosacral ligaments and the back of the vaginal wall and prohibit a herniation of the large intestine into the vaginal cavity. This herniation or enterocele occurs in women who have had hysterectomies and is due in part to the removal of the uterus. To repair the defect the surgeon sutures the apex of the pubocervical and rectovaginal fascia back together. Because the sutures will only solve part of the problem patients who receive an enterocele repair may also require a vaginal vault suspension.
For most vaginal vault suspensions repair of the enterocele is a separately billable procedure only if done with an abdominal approach (57270) rather than a vaginal approach (57268). The rationale is that the abdominal approach represents a separate incision and significantly more work than a vaginal enterocele repair during the same surgery. Likewise the enterocele repair is billable separately from the paravaginal defect repair whether it is an abdominal or a vaginal approach.
Patients may also require a posterior repair. As the name suggests this involves a repair to the posterior wall of the vagina when it is insufficiently supported against the rectum. The rectum protrudes into the vaginal canal causing difficulty in defecation or vaginal “fullness.” In a posterior colporrhaphy the rear vaginal wall is sutured to tighten it and enable it to withstand pressure from the neighboring rectal wall. A posterior repair is coded 57250 (Posterior colporrhaphy repair of rectocele with or without perineorrhaphy) and is separate from vaginal vault suspension or paravaginal defect repairs.
With these other surgical procedures urinary incontinence is often repaired with the Burch anterior urethropexy (51840 Anterior vesicourethropexy or urethropexy [e.g. Marshall-Marchetti-Krantz Burch]; simple). Again this procedure uses sutures to support the structures that have allowed for the displacement of the urethra. Despite fairly liberal bundling rules for other urogynecological procedures Marshall-Marchetti-Krantz (MMK)/Burch repairs are always bundled with the major procedure whether it is a vaginal vault repair or paravaginal defect repair.
Compare the RVUs for the MMK/Burch with other urogynecological procedures performed at the same time as the MMK/Burch may reimburse at a higher level and therefore may be the first service to code.
These major reconstructive surgeries result in damage to the lower urinary tract in about one in 100 cases. Most surgeons perform a cystoscopy at the time of the surgery to ensure that no damage has occurred. The procedure is coded 52000 (Cystourethroscopy [separate procedure]). The problem similar to performing a vaginal vault suspension during a hysterectomy is that there is no diagnosis of bladder damage to warrant the exploratory procedure. It is more of a “look-see” to determine if damage has occurred or if sutures have been placed into the bladder. As with vaginal vault suspensions during hysterectomies documentation with the claim for the cystoscopy should include a detailed note from the physician and excerpts from established medical journals citing statistical support for the exploratory (and preventive) endoscopy.
Stuber also points out that if during the surgery the physician sees blood in the patient’s urine this indicates hematuria (599.7) a diagnosis that supports the cystourethroscopy.
Unfortunately for many of these complex procedures bundling rules vary. Rasmussen reminds that coding for urogynecological surgeries involves research by the coder. “Remember that Correct Coding Initiative edits are imperfect at best ” she says “so don’t stop at those. Consult CPT’s rules for separate procedures the code descriptions and other specialty coding manuals to make sure you’re coding correctly.””