By Alejandra Munoz, CPC, NCICS

 Intersex Surgery, 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

 Vulva, Perineum, and Introitus  Vagina  Cervix Uteri  Corpus Uteri  Oviduct/Ovary  Ovary  In Vitro Fertilization

 Skene’s glands coded with Urinary System, Incision or Excision codes  Categories  Incision  Destruction  Excision  Repair  Endoscopy

 I&D of abscess: vulva, perineal area, or Bartholin’s gland  Marsupialization:  Cyst incised  Drained  Edges sutured to sides to keep cyst open

 Lesions destroyed by variety of methods  Destruction = Eradication not excision  Excision is removal (Divided by simple or extensive destruction)  Destruction: No pathology report

 Biopsy includes:  Local anesthetic  Biopsy  Simple closure  Code based on number of lesions  Place number of lesions on CMS-1500 in 24G

 Extent is:  Simple: Skin and superficial subcutaneous tissues  Radical and deep subcutaneous tissues

 Many plastic repairs  Read notes following category  If repair procedure for wound of genitalia, use Integumentary System code  Endoscopy (56820, 56821)  By means of colposcopy, with or without biopsy

 Codes divided based on service:  Incision  Destruction  Excision  Introduction  Repair  Manipulation  Endoscopy/Laparoscopy

 For non-obstetrics repair  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

 Dilation: speculum inserted into vagina and enlarge 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 (e.g., D&C)

 Colposcopy codes based on purpose:  E.g., biopsy, diagnostic, LEEP  LEEP uses heated wire to excise, AKA diathermy  Includes:  Laparoscopic approach for repairing paravaginal defect

 Enables medical provider to view an endocervical polyp

 It is the narrow, lower end of uterus; services include endoscopy, excision, manipulation, and repair

 Dilatation and Curettage (D&C of uterus)  After dilation, curette scrapes uterus  Do not report postpartum hemorrhage service with  Use Maternity and Delivery code

 Many hysterectomy codes  Based on approach (vaginal, abdominal) and extent (uterus, fallopian tubes, etc.)

 Common procedure  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

 Laparoscopic approach for:  Removal of myomas or uterus  Codes divided by tissue and weight

 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

 Specialized codes used by physicians trained in fertilization procedures  Codes divided by type of procedure and method

 Divided by service:  Antepartum services  Amniocentesis  Fetal non-stress test  Type of delivery  Vaginal delivery  C-section  Delivery after C-Section  Abortion

 Fetal gestation: Approximately 266 days (40 weeks)  EDD: Estimated Date of Delivery (280 days from last menstrual period)  Trimesters:  First: LMP to week 12  Second: week 13 to 27  Third: week 28 to EDD

 Uncomplicated maternity case includes:  Antepartum care (before birth)  Delivery  Postpartum care (after birth)

 Included in delivery  Not reported separately

 Payers differ on reporting format  -22 (unusual procedural services)  -51 (Multiple Procedure)

 Spontaneous: Happens naturally  Incomplete: Requires medical intervention  Missed: Fetus dies naturally during first or second trimester  Septic: Missed abortion with infection

 Medical intervention:  Dilation and Curettage or evacuation (suction removal)  Intra-amniotic injections (saline or urea)  Vaginal suppositories (prostaglandin)

 Buck, C. (2010). Step by Step. Elsevier.