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Boston Scientific — Coding for Pelvic Reconstruction Surgery Webinar (October 2012)
57 slides from Boston Scientific's conference presentation, Oct 24, 2012
Slide 1: Coding for Pelvic Reconstruction Surgery Webinar
Presenter: Melanie Witt, RN, CPC, COBGC, MA Sponsored by Boston Scientific Corporation WH-112905-AA 1 of 57 24OCT2012
Slide 2: Important Information
Important Information The purpose of this presentation is to provide you with general information and key considerations related to pelvic reconstruction procedures in which Boston Scientific products are used in a manner consistent with their labeled indications. Caution: Federal (U.S.) law res
Slide 3: Presenter background
Ms. Witt provides coding and reimbursement assistance to Boston Scientific Corporation relating to their products for female genitourinary conditions. The opinions and recommendations expressed in this presentation are those of the presenter and do not necessarily reflect those of Boston Scienti
Slide 4: Learning objectives
Select appropriate CPT® Codes for each type of repair Understand the role of documentation to ensure fair and timely reimbursement Select appropriate diagnostic linkages in support of procedures performed Understand how payer billing rules can impact reimbursement Effectively report surgic
Slide 5: Documentation and billing basics
See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 5 of 57 24OCT2012
Slide 6: Documentation of what, how and why
Documentation of ◦ What you did ◦ How you did it ◦ Why you did it See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 6 of 57 24OCT2012
Slide 7: Cost of improperly filed claims
An improperly filed claim for payment automatically adds another 30 days before you receive payment ◦ It could be your fault, not the coders Large surgical practices can lose around 20% in revenue due to improperly coded claims ◦ Smaller practices generally lose less revenue due to less volume o
Slide 8: The operative note as billing document
The operative note represents the most important document for justification of reimbursement for surgical services Consider it a stand-alone document Surgeons should reassess the operative note as a billing document and provide the information necessary to expedite reimbursement See important
Slide 9: Important elements of the operative note
Important elements ◦ Pre- and postoperative diagnoses ◦ Procedure performed Try and use CPT® Code terminology ◦ Indications statement ◦ Findings statement ◦ Description of each procedure performed in enough detail to support billing If procedure is very difficult spend some time describing it
Slide 10: Know your payers and appeal denials
Know your payers and their policies ◦ Coding can’t fix a bad contract ◦ Negotiate for the things you want Work with your coders and billers ◦ Be available and open for questions ◦ Plan regular meetings to discuss problems ◦ Make sure someone is watching denials and payer contracted payment amoun
Slide 11: CPT codes for repairs
See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 11 of 57 24OCT2012
Slide 12: Anterior colporrhaphy CPT 57240
Anterior colporrhaphy— CPT® Code 57240: ◦ Usually performed for midline cystocele or cystourethrocele ◦ Basic description: open anterior wall, plicate excess tissue, suture closed, cut off excess ◦ Includes repair of urethrocele if performed CPT Copyright 2011 American Medical Association. All rig
Slide 13: Paravaginal defect repair
Paravaginal defect repair ◦ Repairs a lateral defect ◦ All approaches include cystocele repair (anterior colporrhaphy) ◦ Reattaches the lateral vagina to the ATFP ◦ All CPT® Codes for this repair involve entering the space of Retzius and using sutures to make the attachment Abdominal (CPT Code 5
Slide 14: Rectocele repair and combined procedures
Rectocele repair ◦ Without posterior colporrhaphy: CPT® Code 45560 Documentation will show rectal plication Normally performed by a general surgeon for fecal incontinence ◦ With posterior colporrhaphy: CPT Code 57250 Includes perineorrhaphy Open the posterior vaginal wall, plicate thickene
Slide 15: Enterocele repair
Special case because the 2 stand-alone codes are always bundled (CPT® Codes 57268/57270) Can be repaired at the time of a vaginal hysterectomy ◦ Report inclusive codes only CPT Codes 58263, 58270, 58280, 58292, 58294 Can be repaired at the time of colpopexy ◦ McCall culdoplasty to reduce the
Slide 16: Colpopexy
Colpopexy: ◦ Attach vaginal vault to a supporting structure usually using mesh Use of mesh is not reported separately ◦ Laparoscopic—CPT® Code 57425 ◦ Abdominal—CPT Code 57280 ◦ Vaginal: Sacrospinous or iliococcygeus ligament—CPT Code 57282 Uterosacral or levator myorrhaphy— CPT Code 57283 ◦
Slide 17: Rationale for mesh support
Main rationale is to provide support to the already attenuated or absent connective pelvic floor tissues that have failed See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 17 of 57 24OCT2012
Slide 18: Vaginal mesh kits
Vaginal mesh kits facilitate physician placement and may reduce operative time. ◦ Mesh can be additionally cut or trimmed in OR to fit the patient Physicians often refer to procedures by the name of the product they use ◦ E.g., Uphold® System, Elevate® Prolapse Repair System, Repliform® Matrix,
Slide 19: Reporting the CPT code that fits the repair
You report the CPT® Code that best fits the repair type ◦ Anterior repair Note, even though some mesh systems may anchor the mesh at the arcus tendineus, this is not the same as the work for the paravaginal codes developed by CPT ◦ Posterior repair ◦ Vaginal vault repair Mesh may be bundled by
Slide 20: Mesh systems: uses, attachments, add-on mesh
Name Uses Attachments Add-on Mesh? Uphold® Vaginal Anterior wall, and Sacrospinous Yes, with Support System vaginal vault ligament, with documented repair overlay of anterior pubocervical compartment fascia weakness Pinnacle® Posterior wall Sacrospinous Yes, if rectovaginal Posterior Pelvic repair l
Slide 21: Diagnosis coding
See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 21 of 57 24OCT2012
Slide 22: Purpose of diagnosis coding
Purpose ◦ To provide medical indication for claim payment ◦ Data collection The provider assigns the diagnosis, not the coder Link each procedure or service to it’s own diagnosis Always code to the highest level of specificity ◦ An unspecified code can cause a claim denial or delay of paymen
Slide 23: Medical indication for procedures
Payers reimburse for medically indicated procedures ◦ The diagnosis codes reported establish medical indication and need to be as specific as possible Each surgical procedure performed must be supported by at least 1 diagnostic code that indicates the reason it is necessary for this patient See
Slide 24: Uncodeable diagnoses without more information
Uncodeable Why? Without More Info Uterine prolapse Is it only uterine prolapse or is there vaginal wall prolapse in addition? Genital prolapse What is prolapsing? Uterovaginal It is incomplete or complete prolapse? prolapse Pelvic relaxation Results from lax ligaments, fascia, and muscles supporting
Slide 25: Uncodeable diagnoses without more information (continued)
Uncodeable Why? Without More Info Significant pelvic What is significant? Which areas are prolapsing? prolapse Pelvic organ Which ones? How bad? prolapse Vaginal vault And does she still have her uterus? prolapse Vaginal wall prolapse Anterior or posterior wall? Recurrent distal Was it midline or la
Slide 26: Diagnosis codes for paravaginal repair and colpopexy
Paravaginal defect ◦ 618.02, lateral cystocele repair Colpopexy ◦ 618.09, Vaginal vault prolapse with uterus in place ◦ 618.2-618.4, Vaginal vault prolapse with uterine prolapse ◦ 618.5, Vaginal vault prolapse after hysterectomy McCall, Halban, ◦ 618.6, Vaginal enterocele Moschcowitz culdoplas
Slide 27: Diagnosis codes for anterior and posterior repair
Anterior repair ◦ 618.01, Midline defect ◦ 618.2-618.4, With uterine prolapse Posterior repair ◦ 618.04, Rectocele ◦ 618.2-618.4, With uterine prolapse See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 27 of 57 24OCT2012
Slide 28: Add-on mesh and related procedures
See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 28 of 57 24OCT2012
Slide 29: AMA rationale for CPT 57267
AMA’s rationale for adding CPT® Code 57267 ◦ Native tissues are determined to be weak and inadequate for repair with reconstructive procedures performed for the anterior and posterior compartments of the vagina ◦ The MD decides to insert an intervening prosthetic material (e.g., autograft, allogra
Slide 30: Reporting rules for CPT 57267
CPT® Code 57267 can only be reported when performing a vaginal approach repair ◦ CPT codes 45560, 57240-57265, 57285 only Add-on mesh code is not reported with laparoscopic or abdominal paravaginal repairs, or colpopexy procedures Bill once per vaginal wall repair ◦ Anterior x 1, posterior x 1
Slide 31: Documentation establishing medical need for mesh
Does not establish medical need ◦ “Discussed with patient use of mesh and she consented” ◦ “Mesh was placed” ◦ “anterior repair with mesh” Does establish medical need ◦ “Patient’s native tissues were friable so decision was made to augment repair with mesh” ◦ Findings: “Attenuated rectovaginal t
Slide 32: Cystoscopy after reconstructive surgery
Cystoscopy is a frequently performed procedure after reconstructive surgery ◦ Done to ensure bladder is not compromised by sutures, needles or mesh used in the repair A procedure done by the surgeon to check his work is always included in the surgical procedure Can only be billed for a documen
Slide 33: Cystoscopy documentation examples
“I then performed cystoscopy with above mentioned findings.” ◦ Findings: “There was no trauma to the bladder as seen on cystoscopy at the conclusion of the procedure. Both ureters were seen to efflux clear indigo carmine stained urine.” “Cystoscopy was then done. There is clear urine effluxing f
Slide 34: Cystourethroscopy documentation example
Indications statement: On exam, she was noted to have a grade 3 cystocele, grade 2 uterine prolapse, and grade 1 rectocele. She also demonstrated urethral hypermobility and perineal laxity. Urodynamic testing revealed borderline bladder capacity without objective evidence of stress incontinence wi
Slide 35: Prophylactic repairs not reimbursed
Payers do not reimburse for procedures that fix a problem not yet in evidence ◦ Many physicians believe that prophylactic repair will avoid future surgery for the patient The payer is not interested in this argument, and You cannot fix a coverage problem with coding Reporting a diagnostic co
Slide 36: Robotic-assisted procedures coding
Coded the same as laparoscopic procedures ◦ No additional physician reimbursement for using robot, but you can report that you used the robot (e.g., robot-assistance sacrocolpopexy) CPT® Code 57425, laparoscopic colpopexy HCPCS Code S2900, Surgical techniques requiring use of robotic surgical
Slide 37: Mesh erosion coding
Dx 629.31 (mesh erosion) Revision of graft to repair or remove ◦ CPT® Code 57295 (vaginal approach) Caution! CPT Code 57295 has 13.13 RVUs and is appropriate only for a facility site of service, not office Office removal of eroding mesh using forceps or scissors is CPT Code 58999 only Comp
Slide 38: Billing for surgical complications
You can bill for unexpected complications of the surgery that do not result in a return to the OR….maybe “I can’t pee” would not be unexpected for many uro/gyn procedures Wound dehiscence or infection would be unexpected Medicare always requires a return to the hospital OR to bill for compli
Slide 39: Case studies disclaimer
Results from case studies are not predictive of results in other cases. Results in other cases may vary. See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 39 of 57 24OCT2012
Slide 40: Case 1: patient presentation
28 y/o g5 with a symptomatic vaginal bulge who desired permanent correction. She had documented stress and urge urine loss. She also had symptoms of interstitial cystitis. She was consented for and had a vaginal hysterectomy, BSO, anterior and posterior repair with synthetic graft kit, enterocel
Slide 41: Case 1: claim payment results
CPT® Code 58260, vaginal hysterectomy ◦ linked to 618.3 (uterovaginal prolapse, complete) Line item was paid at 100% of allowable CPT Code 57265-51, combined anterior/posterior repair with enterocele repair ◦ linked to 618.01 (Cystocele, midline), 618.04 (Rectocele) and 625.6 (Stress incontine
Slide 42: Case 1: denied line items
CPT® Code 57267 x 2, insertion of add-on mesh ◦ linked to 625.6 (stress incontinence, female) Line item was denied due to ICD9/procedure code mismatch CPT Code 52000-51, cystoscopy ◦ linked to 625.6 (stress incontinence, female) line item was denied as bundled CPT Copyright 2011 American Med
Slide 43: Case 1: documentation questions
Does the method of billing capture the procedures performed? ◦ Does the documentation support the procedures billed? There is an anterior repair, but Monarc tape was also used. Where is the description of the sling procedure? Where is the rectocele repair described? Which Dx for incontinence
Slide 44: Case 1: coding with RVUs
CPT® Code 57265, combined A&P repair with enterocele repair ◦ linked to 618.3 (uterovaginal prolapse, complete ) - 27.15 RVUs CPT Code 58260-51, vaginal hysterectomy ◦ linked to 618.3 (uterovaginal prolapse, complete ) - 24.69 RVUs CPT Code 57288, sling procedure ◦ linked to 788.33 (mixed inco
Slide 45: Without good documentation vs with good documentation
Without Good With Good Documentation Documentation CPT® Code 58260 vaginal CPT Code 57265 combined hysterectomy – 24.69 RVUs A&P repair with enterocele CPT Code 57265 combined repair – 27.15 RVUs A&P repair with enterocele CPT Code 58260 vaginal repair – 50% of 27.15 RVUs hysterectomy – 50%
Slide 46: Case 2: patient presentation and surgery
Stage III uterine prolapse, Urodynamic stress incontinence, vaginal outlet relaxation, cystocele Surgeon performs bilateral anterior sacrospinous fixation with Uphold® Mesh, anterior repair with Uphold Mesh, TVT- obturator sling system, perineorrhaphy, and cystoscopy Products are labeled for ind
Slide 47: Case 2: documentation gaps
Anterior pubocervical tissue weakness is not documented There is no indication of need for a diagnostic cystoscopy for any reason other than the surgeon checking his work See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 47 of 57 24OCT2012
Slide 48: Case 2: coding and RVUs
CPT® Code 57288 sling procedure ◦ linked to 625.6 - 21.16 RVUs CPT Code 57240-51 anterior repair ◦ linked to 618.3 50% of 19.80 RVUs CPT Code 57282-51 vaginal colpopexy ◦ linked to 618.3 50% of 14.93 RVUs CPT Code 56810-51 ◦ linked to 618.89 50% of 7.74 RVUs Total RVUs: 42.40 RVUs CPT
Slide 49: ICD-9-CM to ICD-10-CM crosswalk
See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 49 of 57 24OCT2012
Slide 50: ICD-9-CM and ICD-10-CM prolapse codes
ICD-9-CM ICD-10-CM 618.00, Unspecified prolapse of No ICD10 equivalent vaginal walls 618.01, Cystocele, midline N81.10, Cystocele, unspecified N81.11, Cystocele, midline 618.02, Cystocele, lateral N81.12, Cystocele, lateral Includes cystourethrocele 618.03, Urethrocele N81.0, Urethrocele only 618.04
Slide 51: ICD-9-CM and ICD-10-CM uterovaginal prolapse codes
ICD-9-CM ICD-10-CM 618.2, uterovaginal prolapse, N81.2, incomplete uterovaginal incomplete prolapse Includes 1st & 2nd degree uterine prolapse, cervical prolapse NOS, uterine prolapse with any form of vaginal wall prolapse 618.3, uterovaginal prolapse, N81.3, complete uterovaginal complete prolapse
Slide 52: ICD-9-CM and ICD-10-CM uterine and vault prolapse codes
ICD-9-CM ICD-10-CM 618.1, Uterine prolapse only No ICD10 equivalent 618.5, Vaginal vault prolapse N99.3, Prolapse of vaginal vault after hysterectomy after hysterectomy 618.6, Vaginal enterocele N81.5, Vaginal enterocele Excludes enterocele with uterine prolapse (N81.2-N81.4) 618.7, Old laceration o
Slide 53: ICD-9-CM and ICD-10-CM tissue weakening codes
ICD-9-CM ICD-10-CM 618.81, Incompetence or N81.82, Incompetence or weakening of pubocervical weakening of pubocervical tissue tissue 618.82, Incompetence or N81.83, Incompetence or weakening of rectovaginal tissue weakening of rectovaginal tissue 618.83, Pelvic muscle wasting N81.84, Pelvic muscle w
Slide 54: Resources
See important notes on the uses and limitations of this information on slide 2. WH-112905-AA 54 of 57 24OCT2012
Slide 55: References
American Medical Association, Current Procedural Terminology, Professional Edition, 2011 International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), 10/01/11 ICD-9-CM Official Guidelines for Coding and Reporting, 10/01/11 Centers for Medicare and Medicaid Servic
Slide 56: Boston Scientific resources and websites
Boston Scientific ◦ www.bostonscientific.com ◦ www.bostonscientific.com/reimbursement ◦ www.pelvic-floor-institute.com American Medical Systems ◦ www.americanmedicalsystems.com/womens_health.html Gynecare ◦ www.clinicalexpertise.com/clinical-focus/pelvic-organ- prolapse See important notes on
Slide 57: Trademark notices
See important notes on the uses and limitations of this information on slide 2. Uphold and Pinnacle are registered trademarks of Boston Scientific Corporation or its affiliates. All other trademarks are property of their respective owners. ©2012 Boston Scientific Corporation or its affiliates. All r
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