Vi Dodd, a certified professional coder at Richmond, Va.-based Medarva Stony Point Surgery Center, spoke with Becker's ASC Review about best practices and guidelines for coding and billing four common outpatient gynecologic procedures.
Here's what she had to share:
1. Laparoscopic myomectomy. The first two steps to coding laparoscopic myomectomy are to determine how many myomas, or fibroids on the wall of the uterus, are being removed and the weight of these myomas.
- CPT code 58545 is appropriate for procedures where one to four myomas are removed or when myomas — regardless of the number — weigh 250 grams or fewer.
- CPT code 58546 is appropriate when five or more myomas that weigh greater than 250 grams are removed.
If the operative report does not make note of the myomas' weight, the coder will need to ask the surgeon, in which case the surgeon should be careful to document the removal and weight of myomas only — not including other tissue. Some centers may use the path report for their coding, however, Ms. Dodd cautions against this practice.
"With the path report, there's shrinkage," she notes. "It's not going to give you the full size to code."
2. Hysteroscopy procedures. There are four main considerations when coding for hysteroscopy procedures:
- Was the hysteroscopy a diagnostic procedure only? If so, use CPT code 58555.
- Were polyp(s) removed or was a biopsy performed? If so, use CPT code 58558.
- Was there lysis of intrauterine adhesions? If so, use CPT code 58559.
- Was a surgical hysteroscopy performed, with removal of fibroid(s)? If so, use CPT code 58561.
A common coding mistake, according to Ms. Dodd, is confusing hysteroscopy procedures with laparoscopy procedures.
"As far as for the fibroid removal, there's one procedure that’s done through a laparoscope and one that done with a hysteroscope," she explains. "You need to make sure you're not confusing the procedures, since it's two completely different codes."
3. Laparoscopic hysterectomy. The first two steps to coding for laparoscopic hysterectomy are to determine which procedure was performed and the size of the uterus.
- Was a supracervical hysterectomy performed on a uterus that weighed fewer than 250 grams? If so, use CPT code 58541.
- Was a supracervical hysterectomy performed on a uterus that weighed fewer than 250 grams, with removal of a tube or ovary? If so, use CPT code 58542.
- Was a total hysterectomy performed on a uterus that weighed fewer than 250 grams? If so, use CPT code 58570.
- Was a total hysterectomy performed on a uterus that weighed fewer than 250 grams, with removal of a tube or ovary? If so, use CPT code 58571.
"One thing that I see in the reports is that it's very easy to confuse a total hysterectomy with a supracervical or vaginal hysterectomy," Ms. Dodd says. Additionally, some laparoscopic procedures are performed to remove only tubes or ovaries, without the uterus, which have a different set of codes.
4. InterStim implantation. A surgeon may implant an InterStim neurostimulator device to treat urinary incontinence. There are two main considerations when coding for this procedure at an ASC:
- Was the peripheral neurostimulator pulse generator inserted? If so, use CPT code 64590.
- Was a permanent lead implanted? If so, use CPT code 64581.
For this procedure, coders should pay particular attention to what health insurance plan the patient is using. Although most payers will reimburse ASCs for these implants, Medicare will not pay separately for the implant, according to Ms. Dodd, because InterStim implantation is considered a device-intensive procedure — so reimbursement for the implants is included in CPT codes 64590 and 64581
"The cost of the implants for this procedure is very expensive," she says. "It is very important to understand what the surgeon is doing."
Caleb Cox, director of business development and physician network for Medarva Healthcare, adds how quality coding can support all of a surgery center's capabilities.
"When you're talking about how quality coding can benefit a surgery center, it's not only on the immediate financial end," explains Mr. Cox.
"It ensures proper and optimized reimbursement, but it can also lead to growth and expansion within service lines. With the depth and scope of coding, it allows the physicians to maximize their billing potential by thinking about all the little steps they did to achieve the end."
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