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CHAPTER 20

CHAPTER 20. REPRODUCTIVE, INTERSEX SURGERY, FEMALE GENITAL SYSTEM, AND MATERNITY CARE AND DELIVERY. Reproductive System Procedure (55920). Reports placement of catheters/needles into pelvic organs/genitalia for subsequent interstitial radioelement application. Intersex Surgery (55970, 55980).

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CHAPTER 20

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  1. CHAPTER 20 REPRODUCTIVE, INTERSEX SURGERY, FEMALE GENITAL SYSTEM, AND MATERNITY CARE AND DELIVERY

  2. Reproductive System Procedure (55920) Reports placement of catheters/needles into pelvic organs/genitalia for subsequent interstitial radioelement application

  3. Intersex Surgery (55970, 55980) There are only 2 codes within subsection Male to female Female to male Complicated procedures completed over extended period of time Performed by multiple physicians with extensive specialized training

  4. Female Genital System Anatomic division: From vulva to ovaries Many bundled services Figure: 20.1A

  5. Female Genital System Subheadings Vulva, Perineum, and Introitus Vagina Cervix Uteri Corpus Uteri Oviduct/Ovary Ovary In Vitro Fertilization

  6. Vulva, Perineum, and Introitus Skene’s glands coded with Urinary System, Incision or Excision codes Group of small mucous glands, lower end of urethra Paraurethral duct Categories Incision Destruction Excision Repair Introduction Manipulation Endoscopy In Vitro Fertilization

  7. Incision Category (56405-56442) • I&D of abscess: Vulva, perineal area, or Bartholin’s gland • Marsupialization: • Cyst incised • Drained • Edges sutured to sides to keep cyst open From Andrews G, editor: Women’s Sexual Health, ed 3, 2005, Elsevier.

  8. Destruction (56501, 56515) Lesions destroyed by variety of methods Destruction = Eradication not excision Excision is removal (Cont’d…)

  9. Destruction (56501, 56515) (…Cont’d) Divided by simple or extensive destruction Complexity based on physician’s judgment Extensive would imply greater physician work, degree of difficulty, or number of lesions destroyed Stated in record 56501/56515 have a global period of 10 days on Medicare Fee Schedule If the patient returns in 2 days for a re-check, it is included in payment for original procedure Destruction: No pathology report

  10. Excision (56605-56740) Biopsy includes: Local anesthetic Biopsy Simple closure Code based on number of lesions Place number of lesions on CMS-1500 in 24G (Cont’d…)

  11. Excision (56605-56740) (…Cont’d) Codes 56605 & 56606 are designated “separate procedures” If another service code from female genital subsection performed at same session, “separate procedure” codes would not be billed separately Vulvectomy: Surgical removal of portion of vulva (56620-56640) Based on extent and size of area removed (Cont’d…)

  12. Excision (56605-56740) (…Cont’d) Extent is: Simple: Skin and superficial subcutaneous tissues Radical: Skin and deep subcutaneous tissues (Cont’d…)

  13. Excision (56605-56740) (…Cont’d) Size: Partial : <80% vular area Complete : >80% vular area Extent and size, on operative report Some vulvectomy codes include lymphadenectomy (56631-56632, 56634-56640) Code 56640 is unilateral procedure and has no code to describe bilateral Bilateral, report 56640-50

  14. Repair (56800-56810) Many plastic repairs Read notes following category If repair procedure for wound of genitalia, use IntegumentarySystem code Endoscopy (56820, 56821) By means ofcolposcopy, with or without biopsy 56606 is add-on (+) code and describes each separate additional lesion biopsied from vulva/perineum Code cannot stand alone, must be billed with 56605

  15. Vagina (57000-57425) Codes divided based on service (e.g., incision, excision)

  16. Introduction (57150-57180) Includes vaginal irrigation, insertion of devices, diaphragm, cervical caps, pessary Report device inserted separately 99070 or HCPCS, such as A4261 (cervical cap) Coverage for supplies will vary based on payer Medicare bundles 99070 into procedure code and A4261 is non-covered Code 57180 has a 10-day global period Figure: 20.5 Vaginal pessary (Arabin type). (Modified from Gabbe SG, Niebyl JR, Simpson JL: Obstetrics: Normal and Problem Pregnancies, ed 5, Philadelphia, 2007, Churchill Livingstone.)

  17. Repair (57200-57335) For nonobstetric repairs Obstetric repairs, use Maternity Care and Delivery codes Global period usually 90 days Review the operative report for specific details relevant to accurate code assignment

  18. Manipulation (57400-57415) Dilation : Speculum inserted into vagina and enlarged using dilator Procedures done under general anesthesia or spinal anesthesia Foreign body removed from vagina without anesthesia, assign E/M code Not appropriate to bill pelvic exam under anesthesia when other related procedures performed at same session Example, D&C

  19. Endoscopy (57420-57426) Colposcopy codes based on purpose e.g., biopsy, diagnostic,LEEP (loop electrocautery excision procedure) LEEP uses heated wire to excise, AKA: diathermy Includes: Laparoscopic approach for repairing paravaginal defects

  20. Colposcopy Figure: 20.6 From Baggish MS: Colposcopy of the Cervix, Vagina, and Vulva: A Comprehensive Textbook, Philadelphia, 2003, Mosby. • Colposcopy enables physician to view an endocervical polyp

  21. Cervix Uteri (57452-57800) Figure: 20.1A • Cervix uteri, narrow, lower end of uterus; services include endoscopy, excision, manipulation, repair

  22. LEEP LEEP, LETZ, or cervical loop diathermy relatively new office procedure Figure: 20.7 From Llewellyn-Jones D: Fundamentals of Obstetrics and Gynaecology, ed 7, 1999, Mosby Ltd.

  23. Excision (57500-57558) Conization codes Conization: Removal of cone of tissue from cervix LEEP technology can be used for conizations Excision codes in cervix uteri describe technique and approach used, as well as component procedures included in some code descriptions

  24. Corpus Uteri (58100-58579) Many complex procedures Often very similar wording in code descriptions Requires careful reading

  25. Excision (58100-58294) • Dilation and curettage (D&C, 58120) of uterus • After dilation, curette scrapes uterus • Do not report postpartum hemorrhage service with 58120 • Use 59160—Maternity and Delivery code • (Cont’d…) From Chabner DE: The Language of Medicine, ed 8, St. Louis, 2007, Saunders.

  26. Excision (58100-58294) • (…Cont’d) • Many hysterectomy codes • Based on approach (vaginal, abdominal) and extent (uterus, fallopian tubes, etc.) • (Cont’d…) Total hysterectomy. (Modified from Chabner DE: The Language of Medicine, ed 8, St. Louis, 2007, Saunders.)

  27. Excision (58100-58294) (…Cont’d) Often secondary procedures performed with hysterectomy Do not code secondary relatedminorprocedures separately

  28. Introduction (58300-58356) Figure: 20.10 • Common procedures • e.g., Insertion of an IUD • Report supply of device separately • Specialized services • e.g., artificial insemination procedures • Used to report physician component of service • (Cont’d…) From Chabner DE: The Language of Medicine, ed 8, St. Louis, 2007, Saunders.

  29. Introduction (58300-58356) (…Cont’d) Component coding Necessary with catheter procedures for hysterosonography Notes following codes indicate radiology guidance component codes

  30. Laparoscopy/Hysteroscopy (58541-58579) Laparoscopic approach for: Removal of myomas or uterus Codes divided by tissue and weight

  31. Laparoscopy • Through abdomen • (Cont’d…) Figure: 20.11

  32. Laparoscopy/Hysteroscopy (58541-58579) (…Cont’d) Figure: 20.12 • Hysteroscopy throughuterus. Surgical laparoscopy with vaginal hysterectomy, 58550

  33. Oviduct/Ovary (58600-58770) Oviduct: Fallopian tube Incision category contains tubal ligations When during same hospitalization as delivery, ligation is coded separately Watch “separate procedure” codes If another related procedure is performed at same session “separate procedures” are not billed separately

  34. Laparoscopy (58660-58679) Based on purpose of procedure e.g., Lysis, lesion removal Caution: If only diagnostic laparoscopy: Do not use Female Genital System codes Use 49320, Digestive System

  35. Ovary Two categories only: Incision and Excision Incision: Primarily for drainage of cysts and abscesses Divided on surgical approach Excision: Biopsy, wedge resection, and oophorectomy

  36. In Vitro Fertilization (58970-58976) Specialized codes used by physicians trained in fertilization procedures Codes divided by type of procedure and method used

  37. Maternity Care and Delivery (59000-59899) Divided by service: Antepartum services Amniocentesis Fetal non-stress test Type of delivery Vaginal delivery C section Delivery after C section Abortion

  38. Maternity Care and Delivery Notes Many notes are “must reading” There are codes describing a global service or portions only (e.g., delivery only)

  39. Gestation Fetal gestation: Approximately 266 days (40 weeks) EDD: Estimated Date of Delivery 280 days from last menstrual period (LMP)

  40. Trimesters First: LMP to Week 12 Second: Weeks13-27 Third: Week 28-EDD

  41. Global Package and Delivery Uncomplicated maternity case includes: Antepartum care (before birth) Delivery Postpartum care (after birth)

  42. Antepartum Care Includes Initial and subsequent H&P Blood pressure Weight Routine urinalysis Fetal heart tones • Monthly visits to 28 weeks • Twice-a-month visits weeks 29 to 36 • Weekly visits from week 37 to delivery (Cont’d…)

  43. Antepartum Care Includes (…Cont’d) Code services not related to antepartum care separately e.g., Pregnant female with complaint of suspicious mole on left shoulder Visits to OB/GYN physician, who is providing antepartum care Service regarding mole not antepartum care

  44. Delivery Includes: Admission to hospital with admitting H&P Management of uncomplicated labor Vaginal or cesarean section delivery Complications coded separately Placement of internal fetal and/or uterine monitors Catheterization or catheter insertion Delivery of placenta Induction of labor Artificial rupture of membranes Injection of local anesthetic Reported separately: Fetal scalp blood sampling External cephalic version Administration of epidural

  45. Postpartum Care Includes Hospital & office visits following delivery Exploration of uterus Episiotomy and repair Repair of cervical, vaginal, or perineal lacerations Placement of a hemostatic pack or agent Normal follow-up care for 6 weeks after delivery: e.g., Hospital visits, office visits Not reported separately

  46. Antepartum Services (59000-59076) Amniocentesis: Insertion of needle into pregnant uterus, withdraws fluid (59000) Ultrasound guidance with this service (76946) Component coding often part of services in subheading (Cont’d…)

  47. Antepartum Services (59000-59706) (…Cont’d) Fetal services: Include stress tests, blood sampling, monitoring, and therapeutic services OB ultrasound codes: 76801-76817

  48. Excision (59100-59160) Postpartum curettage: Removes remaining pieces of placenta or clotted blood (59160) Nonobstetric curettage: 58120 (Corpus Uteri, Excision)

  49. Introduction (59200) Insertion of cervical dilator: Used to prepare cervix for an abortive procedure or delivery Cervicalripeningagents may be introduced to prepare cervix Softens and opens cervix

  50. Cervical Ripening Figure: 20.17 • Bishop Scoring System used to assess cervical ripening

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