Health Information Management

Examine codes for complex OB/GYN procedures

JustCoding News: Outpatient, September 23, 2009

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Operative notes for OB/GYN procedures can be long and complex, and coders need to know how to sift through the detailed information to ensure accurate code assignment.

When coding OB/GYN procedures, ICD-9 codes 630–679 in Chapter 11 (Complications of pregnancy, childbirth, and the puerperium) of the ICD-9 Manual take sequencing priority over other chapters.

When physicians administer services to women who are pregnant, Chapter 11 codes take priority because they are specific to pregnant patients and the complications or coexisting conditions that mothers may have, said Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Marblehead, MA. McCall spoke about OB/GYN procedures during an August 13 HCPro audio conference, Complex OB/GYN Coding Challenges: A Case Study Approach to Correct Code Assignment.

Understand OB-GYN coding basics

Report codes from Chapter 11 in the ICD-9 Manual for conditions that appear in the maternal record only, McCall said.

“I sometimes find it can be confusing, especially if you’re a book coder, and you’re used to looking up codes in the alphabetic index,” McCall said. “It can throw you off when you look up a code under the main term ‘pregnancy,’ and it starts talking about ‘affecting fetus’ or ‘newborn.’ ”

Remember to refer to the 764–779 code series to assign codes for conditions that appear in the baby’s chart, if applicable, said McCall. Because OB cases involve both the mother and the baby, keep in mind that the baby doesn’t get his or her own chart until he or she is actually born, McCall said.

Pay attention to fifth digits for codes 640 – 649 and 651–676. These fifth digits denote the episode of care as follows:

  • 0: Unspecified
  • 1: Delivered with/without mention of antepartum condition
  • 2: Delivered with mention of postpartum complication
  • 3: Ante-partum condition or complication
  • 4: Post-partum condition or complication

Note that antepartum refers to scenarios in which the mother returns home without having given birth yet. However, postpartum refers to scenarios in which patients are readmitted during the postpartum period, which is generally four to six weeks after vaginal deliveries and six to eight weeks after caesarians.

Know that laceration codes are classified by depth

OB-related lacerations are one of the most common surgical procedures following episiotomies or spontaneous OB lacerations, McCall said.

Perineal laceration codes are classified according to their depth as follows:

  • 664.0x for first degree: Lacerations that involve the vaginal or perineal skin
  • 664.1x for second degree: Lacerations that involve the vaginal or perineal skin as well as the pelvic floor, perineal, and vaginal muscles
  • 664.2x for third degree: Lacerations that involve everything described in codes 664.0x, 664.1x, as well as the anal sphincter and rectovaginal septum
  • 664.3x for fourth degree: Lacerations that involve everything described in codes 664.0x, 664.1x, 664.2x, as well as the anal and rectal mucosa
  • 664.4x for unspecified degree 

Note that only fifth digits 0, 1, and 4 apply to these codes.

These lacerations often occur during delivery. For third and fourth degree lacerations, the sphincter muscle that surrounds the anus becomes disrupted, and, in many cases, it can have long-term effects such as incontinence, McCall said. Third and fourth degree lacerations occur more often for patients who are delivering for the first time, she added.

When physicians do not document the length or degree of the laceration, coders must default to the smallest size, says Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, an independent consultant from Melba, ID, who also spoke during the audio conference. It’s best to query the physician in these cases, she added.

Consider this case study in which a patient has notable bleeding after delivery. The physician takes the patient back to the operating room to determine the cause of the bleeding. The physician discovers a 4 cm laceration to the cervix.

For this case, report the following CPT and ICD-9 codes:

  • 59400: For the surgery
  • 57720: For the cervical repair
  • Append modifiers -78 and -51 to indicate that the patient returned to the operating room, and the physician performed a subsequent procedure to the delivery.
  • ICD-9 codes: 660.01, 660.21, 663.31, 665.31, 664.01, and V27.0

Note anatomical site to report ectopic pregnancies

Ectopic pregnancies are defined as those that occur outside of the uterus (e.g., in the fallopian tubes). Causes of ectopic pregnancies include the following:

  • Birth defects of the fallopian tubes
  • Complications of a ruptured appendix
  • Endometriosis
  • Scarring caused by previous pelvic surgery
  • History of salpingitis or pelvic inflammatory disease

The following are common symptoms of an ectopic pregnancy:

  • Abnormal vaginal bleeding
  • Amenorrhea
  • Breast tenderness
  • Lower back pain
  • Mild cramping on one side of the pelvis
  • Nausea
  • Pain in the lower abdomen or pelvic area

Report codes from category 633 for ectopic pregnancies, which are based on the anatomical site:

  • 633.0x: Abdominal
  • 633.1x:: Tubal
  • 633.2x: Ovarian
  • 633.8x: Other
  • 633.9x: Unspecified

Surgical treatment (e.g., a hysterectomy) will depend on the location of the ectopic pregnancy. Refer to CPT codes 59120–59151.

View this case study in which a patient has an ectopic pregnancy. Repeated ultrasounds show a mass adjacent to the left ovary. The physician decides to proceed with a laparoscopic procedure.

For this case, report the following CPT and ICD-9 codes:

  • 59151: For the laparoscopic treatment of the ectopic pregnancy
  • 633.10: For the diagnosis of the ectopic pregnancy

Coders must examine the operative note to determine whether this was a laparoscopic or open procedure, Webb said. Also, review the pathology report to verify the diagnosis code.

Understand difference between tubal ligations and occlusions

Tubal ligation refers to when physicians sever and then tie fallopian tubes to prevent fertility. Tubal occlusion refers to when physicians block the fallopian tubes either via a band, ring, or clip.

Refer to the following CPT codes for tubal ligations:

  • 58600: Report this code for a standalone procedure
  • 58605: Report this code for a tubal ligation following a delivery (during the same hospitalization)
  • +58611: Report this add-on code when the physician performs a tubal ligation during another surgery (e.g., a c-section or abdominal surgery)

For tubal occlusions, refer to CPT codes 58615 (for an open procedure) and 58670–58671 (for laparoscopic procedures).

Know that endometriosis codes specify site

Endometriosis refers to an abnormal growth of tissue such as that found within the lining of the uterus and in other anatomical locations (e.g., abdomen, ovaries, or fallopian tubes). The cause of endometriosis is idiopathic (or unknown). However, one theory states that people with immune system or hormonal problems are at a higher risk for developing the condition.

Currently, there is no cure for endometriosis; however, physicians may prescribe analgesics (e.g., aspirin or nonsteroidal anti-inflammatory drugs) or even mild narcotics, such as codeine, for pain relief. Some physicians may place patients on hormonal therapy. In some cases, physicians may consider performing hysterectomies.

Consider the following ICD-9 codes from category 617, which identify the specific site where the endometriosis exists:

  • 617.1: Uterus
  • 617.2: Ovary
  • 617.3: Fallopian tube
  • 617.4: Rectovaginal septum and vagina
  • 617.5: In scar of skin
  • 617.8: Other specified sites
  • 617.9: Unspecified site

An American Hospital Association Coding Clinic, first quarter, 1995 addressed coding for endometriosis that caused the patient to become infertile. The guidance states that coders should code both the endometriosis (ICD-9 code 617.x) as well as the infertility (ICD-9 code 628.x).

Learn about procedure variations to code hysterectomies

Some physicians may resort to hysterectomies to treat endometriosis. There are a number of codes for these procedures:

  • Total abdominal: CPT codes 58150–58152 and 58200
    • Laparoscopic: CPT codes 58570–58573
  • Supracervical (subtotal) abdominal: CPT code 58180
    • Laparoscopic: CPT codes 58541–58544
  • Radical abdominal: CPT code 58210 
    • Laparoscopic: CPT code 58548
  • Pelvic exenteration for GYN malignancy: CPT code 58240
  • Vaginal: CPT codes 58260–58294
    • Laparoscopic: CPT codes 58550–58554
  • Subtotal or total hysterectomy after cesarean delivery: CPT add-on code 59525

CPT Assistant from June 2003 addressed the fact that sometimes during a hysterectomy, physicians may document that they have removed myomas. This guidance states that removal of a myoma is considered an inclusive component of the complex vaginal and excisional hysterectomy codes. Therefore, this part of the procedure is not separately reportable.

Editor’s note: To learn more about Bartholin’s gland and genital prolapsed, and to access additional OB/GYN case studies, purchase a copy of HCPro’s August 13 audio conference, Complex OB/GYN Coding Challenges: A Case Study Approach to Correct Code Assignment.

E-mail Webb at loriwebb@sarmc.org.



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