1. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 CHAPTER 25 REPRODUCTIVE, INTERSEX SURGERY, FEMALE GENITAL SYSTEM, AND MATERNITY CARE AND DELIVERY

2. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 Reproductive System Procedures (55920) Reports placement of catheters/needles into pelvic organs/genitalia for subsequent interstitial radioelement application

3. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Female Genital System Anatomic division: From vulva to ovaries Many bundled services Figure: 25.1A

5. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Female Genital System Subheadings Vulva, Perineum, and Introitus Vagina Cervix Uteri Corpus Uteri Oviduct/Ovary Ovary In Vitro Fertilization

6. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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 –Endoscopy

7. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 Incision Category (56405-56442) From Andrews G, editor: Women’s Sexual Health, ed 3, 2005, Elsevier. I&D of abscess: Vulva, perineal area, or Bartholin’s gland Marsupialization: –Cyst incised –Drained –Edges sutured to sides to keep cyst open

8. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 Destruction (56501, 56515) Lesions destroyed by variety of methods –Destruction = Eradication not excision Excision is removal (Cont’d…)

9. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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 56606 is add-on (+) code and describes each separate additional lesion biopsied from vulva/perineum –Code cannot stand alone, must be billed with 56605 Vulvectomy: Surgical removal of portion of vulva (56620- 56640) Based on extent and size of area removed (Cont’d…)

12. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Excision (56605-56740) (…Cont’d) Extent is: Simple: Skin and superficial subcutaneous tissues Radical: Skin and deep subcutaneous tissues (Cont’d…)

13. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 Excision (56605-56740) (…Cont’d) Size: –Partial: <80% vulvar area –Complete: >80% vulvar 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 Repair (56800-56810) 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

15. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 Vagina (57000-57426) Codes divided based on service (e.g., incision, excision)

16. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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 Vaginal pessary (Arabin type). (Modified from Gabbe SG, Niebyl JR, Simpson JL: Obstetrics: Normal and Problem Pregnancies, ed 5, Philadelphia, 2007, Churchill Livingstone.) Figure: 25.5

17. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20 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.

21. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21 Cervix Uteri (57452-57800) Figure: 25.1A Cervix uteri, narrow, lower end of uterus; services include endoscopy, excision, manipulation, repair

22. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22 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.

23. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24 Corpus Uteri (58100-58579) Many complex procedures –Often very similar wording in code descriptions –Requires careful reading

25. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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…)

26. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 26 (…Cont’d) Many hysterectomy codes –Based on approach (vaginal, abdominal) and extent (uterus, fallopian tubes, etc.) (Cont’d…) Excision (58100-58294) Figure: 25.1B

27. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 27 Excision (58100-58294) (…Cont’d) Often secondary procedures performed with hysterectomy Do not code secondary related minor procedures separately

28. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 28 Introduction (58300-58356) 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 physician component of service (Cont’d…) Figure: 25.10

29. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 29 Introduction (58300-58356) (…Cont’d) Component coding –Necessary with catheter procedures for hysterosonography –Notes following codes indicate radiology guidance component codes

30. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 30 Laparoscopy/Hysteroscopy (58541-58579) Laparoscopic approach for: –Removal of myomas or uterus –Codes divided by tissue and weight

31. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 31 Through abdomen (Cont’d…) Laparoscopy Figure: 25.11

32. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 32 Laparoscopy/Hysteroscopy (58541-58579) (…Cont’d) Figure: 25.12 Hysteroscopy through uterus. Surgical laparoscopy with vaginal hysterectomy, 58550

33. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 39 Gestation Fetal gestation: Approximately 266 days (40 weeks) EDD: Estimated Date of Delivery –280 days from last menstrual period (LMP)

40. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 40 Trimesters First: LMP to Week 12 Second: Weeks 13-27 Third: Week 28-EDD

41. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 41 Global Package and Delivery Uncomplicated maternity case includes: –Antepartum care (before birth) –Delivery –Postpartum care (after birth)

42. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 46 Antepartum and Fetal Invasive 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 47 Antepartum Services (59000-59076) (…Cont’d) Fetal services: Include stress tests, blood sampling, monitoring, and therapeutic services OB ultrasound codes: 76801-76828

48. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 48 Excision (59100-59160) Postpartum curettage: Removes remaining pieces of placenta or clotted blood (59160) Nonobstetric curettage: 58120 (Corpus Uteri, Excision)

49. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 49 Introduction (59200) Insertion of cervical dilator: Used to prepare cervix for an abortive procedure or delivery Cervical ripening agents may be introduced to prepare cervix –Softens and opens cervix

50. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 50 Cervical Ripening Figure: 25.17 Bishop Scoring System used to assess cervical ripening

51. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 51 Repair (59300-59350) Only for repairs during pregnancy Not for repairs done during delivery or after pregnancy

52. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 52 Routine Global Obstetric Care 59400, Vaginal delivery 59510, Cesarean delivery 59610, Vaginal delivery after previous cesarean delivery (VBAC) 59618, Cesarean delivery following attempted vaginal delivery after previous cesarean delivery

53. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 53 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 31, Philadelphia, 2007, Saunders. Included in delivery Not reported separately Figure: 25.13 Figure: 25.14

54. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 54 Physician Provides Only Portion of Global Care 59409, Vaginal delivery only 59514, Cesarean delivery only 59612, Vaginal delivery only, after previous cesarean delivery 59620, Cesarean delivery only, following attempted vaginal delivery, after previous cesarean delivery

55. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 55 Delivery of Twins Payers differ on reporting format –-22 (Unusual Procedural Services) –-51 (Multiple Procedures)

56. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 56 Abortion Services (59812-59857) Spontaneous: Happens naturally Incomplete: Requires medical intervention Missed: Fetus dies naturally during first or second trimester Septic: Missed abortion with infection (Cont’d…)

57. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 57 Abortion Services (59812-59857) Medical intervention –Dilation and curettage or evacuation (suction removal) –Intra-amniotic injections (saline or urea) –Vaginal suppositories (prostaglandin) (…Cont’d)

58. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 58 Conclusion CHAPTER 25 REPRODUCTIVE, INTERSEX SURGERY, FEMALE GENITAL SYSTEM, AND MATERNITY CARE AND DELIVERY