Here’s where you can bypass the edits with modifier 59.
The Correct Coding Initiative (CCI) version 16.0 didn’t overlook the hysterectomy, vaginal graft, and colpopexy codes — nor should you. To make sense of the deletions, break these additions into mutually exclusive and non-mutually exclusive.
Note: In all these cases — except those involving the anesthetic injection codes, you can bypass the edits with a modifier (such as 59, Distinct procedural services). You must have documentation to support the modifier’s use.
Cross Out This Hysterectomy Bundle
CMS deleted the non-mutually exclusive bundle of 58292 (Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube[s] and/or ovary[s], with repair of enterocele) as the column 2 code to 58294 (… with repair of enterocele), but then re-added it in reverse order.
Code 58292 is the column 1 code, and 58294 is the column 2 code. You won’t get paid for a column 2 code performed on the same day as the associated column 1 code – unless the edits permit you to use a modifier, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, consultant with MJH Consulting in Denver.
Rationale: Reversing the order corrects the fact that 58292 has a higher relative value unit (RVU). Also, CMS does not consider the two codes mutually exclusive. The only difference between these two vaginal hysterectomy codes is that one includes removal of the tubes and ovaries, while the other does not.
Make Sense of These Mutually Exclusive Edits
Hysterectomy: The first set of mutually exclusive edits affect hysterectomy procedures. Codes 58263 (Vaginal hysterectomy, for uterus 250 g or less; with removal of tube[s], and/or ovary[s], with repair of enterocele) and 58270 (Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele) are now part of 58280 (Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele). You cannot report more than one vaginal hysterectomy on one patient. Hence, these three codes are mutually exclusive procedures.
You can apply the same logic to codes 58292 (Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube[s] and/or ovary[s], with repair of enterocele) and 58294 (… with repair of enterocele), which now include the work represented by 58280.
IPPE: Additionally, CMS bundles G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment) as mutually exclusive to all problem E/M codes (99201-99215, Office or other outpatient visit …). To bypass this edit, you’ll have to use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the problem E/M code.
Medicare rules do permit the preventive visit to be billed in addition to a significant problem addressed at the same visit. Think of it this way: “If an ob-gyn performs an IPPE on the same day as a sick visit, then you should consider the sick visit bundled into the IPPE. However, you can still bill the sick visit separately if you used a modifier 25 and — what’s vital — have separate documentation to support it,” Dianne Wilkinson, director of quality assurance with MedSouth Healthcare in Dyersburg, Tenn.
Apply Older Rationale to New Non-Mutually Exclusive Edits
Finally, keep your urodynamic claims zipping through processing by following these non-mutually exclusive edits. The majority of them mimic older (now defunct) bundles. Remember: For non-mutually exclusive edits, the column 1 code generally represents the comprehensive service, and the column 2 code is the component that is part of the more extensive column 1 procedure.
Urodynamics: The new urodynamic codes (51727-51729, Complex cystometrogram …) now have the same bundled codes as 51726 (Complex cystometrogram [e.g., calibrated electronic equipment]). Plus, the new urodynamic codes include the same CCI edits you applied to deleted codes 51772 (Urethral pressure profile studies [UPP] [urethral closure pressure profile], any technique) and 51795 (Voiding pressure studies; bladder voiding pressure, any technique).
Also, CCI 16.0 bundles new codes 51728 (Complex cystometrogram [ie, calibrated electronic equipment]; with voiding pressure studies [i.e., bladder voiding pressure], any technique) and 51729 (… with voiding pressure studies [i.e., bladder voiding pressure] and urethral pressure profile studies [i.e., urethral closure pressure profile], any technique) into 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry). The reason provided is “HCPCS/CPT code definition,” but you won’t find any such note in CPT indicating you cannot bill these two codes together. As with all the edits mentioned in this article (except the injections), you can bypass these edits with modifier 59.
Vaginal graft: Also new from CCI 16.0 is the edit that bundles 57426 (Revision [including removal] of prosthetic vaginal graft, laparoscopic approach) into 57296 (Revision [including removal] of prosthetic vaginal graft; open, abdominal approach). The reason is that 57426 represents the most extensive procedure. Additionally, 57426 now includes the same bundles that CCI included with the codes for the other approaches (57295-57296).
Colpopexy: Code 57283 (Colpopexy, vaginal; intra-peritoneal approach [uterosacral, levator myorrhaphy]) now includes all codes that describe a vaginal hysterectomy with enterocele repair (58270, 58280, and 58292). Rationale: These bundles comply with CPT instructions indicating that you should not bill this type of colpopexy separately when the vaginal hysterectomy also corrects for an enterocele.
Injections: Lastly, CCI 16.0 adds new injection codes 64490 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], cervical or thoracic; single level) and 64493 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level) to almost every code in CPT. These edits constitute 80 percent of the 23,000 changes. As Medicare does not pay the surgeon to administer any anesthesia during the procedure he or she performs, these edits shouldn’t come as a surprise.
Request 2 free sample issues of the Ob-gyn Coding Alert here.
Confused by which codes are new? Order your CD of Melanie Witt’s 2010 Ob-Gyn Coding Update.
Don’t let the 2010 coding updates block-up your urogynecology coding. Learn more about these changes at Dr. Michael Ferragamo’s 2010 Urology Coding Update.
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