Slide 1 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CHAPTER 25 REPRODUCTIVE, INTERSEX SURGERY, FEMALE GENITAL SYSTEM, AND MATERNITY CARE AND DELIVERY

Slide 2 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Reproductive System Procedures (55920) Reports placement of catheters/needles into pelvic organs/genitalia for subsequent interstitial radioelement application

Slide 3 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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

Slide 4 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Female Genital System Anatomic division: From vulva to ovaries Many bundled services Figure: 25.1A

Slide 5 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Female Genital System Subheadings Vulva, Perineum, and Introitus Vagina Cervix Uteri Corpus Uteri Oviduct/Ovary Ovary In Vitro Fertilization

Slide 6 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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 –Endoscopy

Slide 7 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Incision Category ( ) From Andrews G, editor: Women’s Sexual Health, ed 3, 2005, Elsevier. Marsupialization I&D of abscess: Vulva, perineal area, or Bartholin’s gland _____________: –Cyst incised –Drained –Edges sutured to sides to keep cyst open

Slide 8 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Destruction (56501, 56515) Lesions destroyed by variety of methods –Destruction = _________ not excision Excision is removal (Cont’d…) Eradication

Slide 9 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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 ________ report pathology

Slide 10 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Excision ( ) Biopsy includes: –____ anesthetic –Biopsy –______ closure Code based on ______ of lesions Place number of lesions on CMS-1500 in ___ (Cont’d…) Local Simple number 24G

Slide 11 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Excision ( ) (…Cont’d) Codes & are designated “separate procedures” –If another service code from female genital subsection performed at same session, “separate procedure” codes would not be billed separately is add-on (+) code and describes each separate additional lesion biopsied from vulva/perineum –Code cannot stand alone, must be billed with Vulvectomy: Surgical removal of portion of vulva ( ) Based on _____ and size of area removed (Cont’d…) extent

Slide 12 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Excision ( ) (…Cont’d) Extent is: ______ : Skin and superficial subcutaneous tissues ______: Skin and deep subcutaneous tissues (Cont’d…) Simple Radical

Slide 13 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Excision ( ) (…Cont’d) Size: –______: <80% vulvar area –________: >80% vulvar area Extent and size, on operative report Some vulvectomy codes include lymphadenectomy ( , ) Code is unilateral procedure and has no code to describe bilateral –Bilateral, report Partial Complete

Slide 14 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Repair ( ) Many plastic repairs Read notes following category –If repair procedure for wound of genitalia, use ____________ System code Endoscopy (56820, 56821) –By means of _________, with or without biopsy Integumentary colposcopy

Slide 15 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Vagina ( ) Codes divided based on service (e.g., incision, excision)

Slide 16 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Introduction ( ) Includes vaginal irrigation, insertion of devices, diaphragm, cervical caps, pessary Report ______ inserted separately –99070 or HCPCS, such as A4261 (cervical cap) Coverage for supplies will vary based on payer Medicare bundles into procedure code and A4261 is non- covered Code has a 10-day global period device Vaginal pessary (Arabin type). (Modified from Gabbe SG, Niebyl JR, Simpson JL, Landon MB, Galan H, Jauniaux ERM, Driscoll DA: Obstetrics: Normal and Problem Pregnancies, ed 6, Philadelphia, 2012, Saunders.) Figure: 25.5

Slide 17 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Repair ( ) 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

Slide 18 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Manipulation ( ) ______: Speculum inserted into vagina and enlarged using dilator Procedures done under ______ 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 Dilation general

Slide 19 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Endoscopy ( ) Colposcopy codes based on purpose –e.g., biopsy, diagnostic, _____ (loop electrocautery excision procedure) –LEEP uses heated wire to excise, AKA: diathermy –Includes: Laparoscopic approach for repairing paravaginal defects LEEP

Slide 20 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Colposcopy Figure: 25.6 Colposcopy enables physician to view an endocervical polyp From Baggish MS: Colposcopy of the Cervix, Vagina, and Vulva: A Comprehensive Textbook, Philadelphia, 2003, Mosby.

Slide 21 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cervix Uteri ( ) Figure: 25.1A Cervix uteri, narrow, lower end of uterus; services include endoscopy, excision, manipulation, repair

Slide 22 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. LEEP LEEP, LETZ, or cervical loop diathermy relatively new office procedure Figure: 25.7 From Llewellyn-Jones D: Fundamentals of Obstetrics and Gynaecology, ed 7, 1999, Mosby Ltd.

Slide 23 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Excision ( ) Conization codes –Conization: Removal of cone of tissue from cervix ____ 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 LEEP

Slide 24 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Corpus Uteri ( ) Many complex procedures –Often very similar wording in code descriptions –Requires careful reading

Slide 25 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Excision ( ) Dilation and curettage (D&C, _____) of uterus –After dilation, curette scrapes uterus Do not report postpartum hemorrhage service with –Use _____—Maternity and Delivery code (Cont’d…)

Slide 26 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. (…Cont’d) Many hysterectomy codes –Based on ________ (vaginal, abdominal) and ______ (uterus, fallopian tubes, etc.) (Cont’d…) Excision ( ) approach extent Figure: 25.1B

Slide 27 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Excision ( ) (…Cont’d) Often secondary procedures performed with hysterectomy Do not code secondary related _____ procedures separately minor

Slide 28 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Introduction ( ) From Goldman CC, Snyder TK: Differential Diagnosis for Physical Therapists: Screening for Referral, ed 5, St. Louis, 2013, Saunders. Common procedures –e.g., Insertion of an IUD Report supply of device separately Specialized services –e.g., artificial insemination procedures Used to report ________ component of service (Cont’d…) physician Figure: 25.10

Slide 29 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Introduction ( ) (…Cont’d) Component coding –Necessary with catheter procedures for hysterosonography –Notes following codes indicate _______________ component codes radiology guidance

Slide 30 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Laparoscopy/Hysteroscopy ( ) Laparoscopic approach for: –Removal of myomas or uterus –Codes divided by tissue and weight

Slide 31 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Through ________ (Cont’d…) Laparoscopy Figure: abdomen

Slide 32 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Laparoscopy/Hysteroscopy ( ) (…Cont’d) Figure: uterus Hysteroscopy through _____. Surgical laparoscopy with vaginal hysterectomy, 58550

Slide 33 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Oviduct/Ovary ( ) Oviduct: Fallopian tube Incision category contains tubal ligations –When during same hospitalization as delivery, ligation __ coded separately Watch “separate procedure” codes –If another related procedure is performed at same session “separate procedures” are not billed separately is

Slide 34 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Laparoscopy ( ) Based on purpose of procedure –e.g., Lysis, lesion removal Caution: If only diagnostic laparoscopy: –Do not use Female Genital System codes –Use _____, Digestive System 49320

Slide 35 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Ovary Two categories only: Incision and Excision ______: Primarily for drainage of cysts and abscesses –Divided on surgical approach _______: Biopsy, wedge resection, and oophorectomy Incision Excision

Slide 36 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. In Vitro Fertilization ( ) Specialized codes used by physicians trained in fertilization procedures –Codes divided by type of procedure and ______ used method

Slide 37 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Maternity Care and Delivery ( ) Divided by service: –Antepartum services Amniocentesis Fetal non-stress test –Type of delivery Vaginal delivery C section Delivery after C section –Abortion

Slide 38 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Maternity Care and Delivery Notes Many notes are “must reading” There are codes describing a global service or portions only (e.g., delivery only)

Slide 39 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Gestation Fetal gestation: Approximately ___ days (40 weeks) EDD: _______________________ –___ days from last menstrual period (LMP) 266 Estimated Date of Delivery 280

Slide 40 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Trimesters First: LMP to Week __ Second: Weeks __-27 Third: Week __-EDD

Slide 41 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Global Package and Delivery Uncomplicated maternity case includes: –_________ care (before birth) –Delivery –_________ care (after birth) Antepartum Postpartum

Slide 42 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Antepartum Care Includes Initial and subsequent H&P Blood pressure Weight Routine urinalysis Fetal heart tones Monthly visits to __ weeks Twice-a-month visits weeks __ to __ Weekly visits from week __ to delivery (Cont’d…)

Slide 43 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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

Slide 44 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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

Slide 45 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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 _ weeks after delivery: –e.g., Hospital visits, office visits –Not reported separately 6

Slide 46 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Antepartum and Fetal Invasive Services ( ) ____________: Insertion of needle into pregnant uterus, withdraws fluid (59000) –Ultrasound guidance with this service (____) Component coding often part of services in subheading (Cont’d…) Amniocentesis 76946

Slide 47 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Antepartum Services ( ) (…Cont’d) Fetal services: Include stress tests, blood sampling, monitoring, and therapeutic services OB ultrasound codes:

Slide 48 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Excision ( ) __________ curettage: Removes remaining pieces of placenta or clotted blood (59160) __________ curettage: (Corpus Uteri, Excision) Postpartum Nonobstetric

Slide 49 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Introduction (59200) Insertion of cervical _____: Used to prepare cervix for an abortive procedure or delivery Cervical _______ agents may be introduced to prepare cervix –Softens and opens cervix dilator ripening

Slide 50 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Cervical Ripening Figure: Bishop Scoring System used to assess cervical ripening

Slide 51 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Repair ( ) Only for repairs during pregnancy Not for repairs done during delivery or after pregnancy

Slide 52 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Routine Global Obstetric Care _____, Vaginal delivery _____, Cesarean delivery _____, Vaginal delivery after previous cesarean delivery (VBAC) _____, Cesarean delivery following attempted vaginal delivery after previous cesarean delivery

Slide 53 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Episiotomies and Use of Forceps From Roberts JR, Hedges JR, editors: Clinical Procedures in Emergency Medicine, ed 4, Philadelphia, 2004, Saunders. From Dorland's Illustrated Medical Dictionary, ed 32, Philadelphia, 2012, Saunders. Included in delivery Not reported separately Figure: Figure: 25.14

Slide 54 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Physician Provides Only Portion of Global Care _____, Vaginal delivery only _____, Cesarean delivery only _____, Vaginal delivery only, after previous cesarean delivery _____, Cesarean delivery only, following attempted vaginal delivery, after previous cesarean delivery

Slide 55 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Delivery of Twins Payers differ on reporting format –___ (Unusual Procedural Services) –___ (Multiple Procedures)

Slide 56 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Abortion Services ( ) ___________ : Happens naturally _________: Requires medical intervention ______: Fetus dies naturally during first or second trimester _____: Missed abortion with infection Spontaneous Incomplete Missed Septic (Cont’d…)

Slide 57 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Abortion Services ( ) Medical intervention –Dilation and curettage or evacuation (______ removal) –Intra-amniotic injections (_____ or urea) –Vaginal suppositories (prostaglandin) suction saline (…Cont’d)

Slide 58 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Conclusion CHAPTER 25 REPRODUCTIVE, INTERSEX SURGERY, FEMALE GENITAL SYSTEM, AND MATERNITY CARE AND DELIVERY