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AQUIRE

Coding Q&A - General

Coding Q&A - Mesh

Coding Q&A - Office Based Procedures

Questions & Answers

AQUIRE

What is a clinical registry?

A clinical registry is an organized system that collects uniform data (clinical and patient-reported) to evaluate specified outcomes for a population defined by a particular condition. With the increasing usage of EHRs, registries have emerged as valuable solutions for harnessing the power of information technology to capture statistically-relevant, evidence-based data to aid in decisions regarding the most optimal patient care. Such registries are already being successfully used within other medical specialties and medical associations, including the American College of Cardiology and the Society of Thoracic Surgeons.

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Why is AUGS providing this technology resource?

AUGS is committed to continually improving and innovating patient care for women suffering with pelvic floor disorders. With the increasing adoption of EHRs and other advances in technology, physicians now have the ability to perform their own data analysis to inform better clinical decision-making. Using disease registries in this manner is the future of medicine, as evidenced by the success of the registries developed by the American College of Cardiology and the Society of Thoracic Surgeons. The timing is right for urogynecologists to be among the early adopters in strategically deploying information technology to drive quality improvement.

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Is AQUIRE being developed as part of the Accountable Care Act or other government mandate?

Clinical data registries pre-date healthcare reform by two decades. They are not mandated as part of health care reform, however with the Centers for Medicare and Medicaid Services (CMS) implement the Medicare Access and CHIP Reauthorization Act of 2016 which will move physician payment more to quality and value-based payments, participation in a quality-focused registry will help health care providers in reporting quality data to CMS for these programs. Registry participation will still be voluntary for the Medicare program, however; it will provide you with clinical data that allows you to benchmark your performance and drive improvement in patient outcomes.

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Is AUGS capable of delivering a quality information technology solution?

AUGS is partnering with FIGmd, Inc. to develop AQUIRE, the AUGS Urogynecology Quality Registry. FIGmd, specializes in integrating EHRs with registries, and has developed and maintained registries for the American College of Cardiology and the AUA and has completed integration projects for more than 50 major EHRs and is capable of working quickly with new EHR systems.

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How will it affect my practice workflow?

AQUIRE has been designed to minimize your participation overhead and time spent on data entry while immediately delivering valuable tools that your practice can use. Many clinical registries include laborious data entry, confusing technology and little immediate return on effort. AQUIRE avoids these problems.

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What data would I have access to as an AQUIRE participant?

AQUIRE allows you to run quality reports that provide clinician-, practice- and national-level results for all measures. Each participant has access to their own performance data. In addition, registry participants can compare their performance and outcomes to similar practices at the regional and national level. It is also possible to generate comparative analysis within a physician’s own practice.

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Is it necessary to have an EHR system to participate in AQUIRE?

At this time the AQUIRE Registry does not integrate with any Electronic Health Record systems, it is a very user-friendly, web-based data entry tool for ease of use. We anticipate the AQUIRE Registry to integrate with EHR’s by 2018. 

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Can the registry data be used for the Merit Incentive Payment System (MIPS) reporting?

Yes. For calendar year 2017 AQUIRE will apply to receive approval as a Qualified Clinical Data Registry (QCDR) to help practices report clinical quality data for increased physician reimbursement.

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How can AQUIRE inform me about my patient population?

You'll be able to monitor patient care, track interventions and evaluate outcomes at a population level. AQUIRE allows users to run queries based on the demographics of your patient population for those conditions addressed in AQUIRE.

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What identifiable points will be associated with my data?

Practices/providers that join AQUIRE enter into an agreement with FIGmd, which includes a HIPAA-compliant Business Associate Agreement. Personal Health Information and identifiable provider information will be captured and stored by AQUIRE in accordance with federal and state laws and regulations, though AQUIRE will not have read access to any identifiable provider or practice data.

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Who will have access to my data?

AQUIRE collects, stores and reports data on a provider’s behalf, taking every measure possible to safeguard it. AUGS' technology partner, FIGmd, is compliant with all local and federal regulations governing these areas, including HIPAA provisions and the recently updated provisions as part of the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health Act.

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How will AUGS use the data in AQUIRE?

Based on the aggregate data, AUGS will be able to publish benchmarks that can be used to assess a urogynecologists’ outcomes, practice patterns and utilization of new technology to look at overall trends in the patient population. AQUIRE data will begin to identify gaps in practice patterns which will provide AUGS with insights into future educational programming and service offerings for members.

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Can or will data from AQUIRE be used by any health plans to evaluate physician performance?

This is not a planned feature.

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Coding Q&A - General

Is it OK to code for total vaginectomy (57110) at the time of colpocleisis (57120) or is it implicit? Any way to differentiate a Leforte colpocleisis from a post hysterectomy colpocleisis during coding?

Per the AUGS Coding committee, 57120 is the correct choice when performing a colpocleisis, whether or not a uterus is present. Vaginectomy cannot be billed simultaneously with colpocleisis, nor is it an appropriate code to use as an alternative to colpocleisis.The clinical vignette for vaginectomy implies that the entire vaginal wall is removed, as a treatment for vaginal cancer.

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What would be the best CPT code to reflect a vaginal denervation procedure? Ingelman-Sundberg denervation?

Per the AUGS Coding Committee, the Ingelman-Sundberg denervation procedure does not have a specific CPT code assigned to capture the work and intensity of the procedure.

The correct method to code the procedure would subsequently fall into 58999, unlisted GYN procedure. Reporting this code for reimbursement requires explanation of the procedure to CMS by inclusion of the Op Report and suggested comparative codes with similar work, time, and intensity. CMS typically reimburses for this code with appropriate documentation, however, with delayed time of processing.

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How do I code for a revision of a vaginal cuff with removal of granulation tissue and excision of suture due to extrusion of the permanent uterosacral sutures (gortex) one year post op?

Per the AUGS Coding Committee, Coding for vaginal cuff repairs and revisions can be challenging depending on the need for the revision.

Based on the information provided the committee’s response would be to code 58999, unlisted procedure, female genital system, non-obstetric.

When the code is submitted be sure to include the op report with explicit description of the procedure performed. Additionally provide a suggested reimbursement based on a similar procedure in terms of time and complexity. Typically insurers will reimburse at an appropriate amount based on your submitted information. However, be aware your revenue will be delayed due to the nature of the submission. Direct communication with your carrier would be warranted if any further questions for this submission should arise.

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I schedule urodynamics with my NP for a preop patient and schedule her to return at least 1 day later to discuss the results, perform cystoscopy, counsel her about surgical options and schedule surgery (25 min of face to face not including cystoscopy). Can I bill both cystoscopy code and a level 4 return visit justified by the face to face time or I am only allowed to bill the procedure?

Per the AUGS Coding Committee, you cannot bill for the E&M services in the scenario that you describe. Urodynamics requires direct physician supervision, which means the physician must be present in the office suite at the time the services are performed. The professional component of urodynamics includes interpretation of and discussion of the results of the studies with the patient. You cannot bill to discuss the results on the following day, since this service is already included, and it would be considered inappropriate unbundling to have a separate encounter on the following day. In general, you should only bill for the procedure, not an additional E&M service unless it is being done for an entirely separate reason with completely unrelated and separate documentation. You need to be careful about scheduling a patient to complete two procedures (cysto and Urodynamics) on separate dates for the same reason within a short time period as this can be interpreted as an attempt to inappropriately unbundle the two procedures to avoid the financial reduction in payment secondary to the multiple procedure modifier.

In summary, you cannot bill separately for discussion and interpretation of the test results. Since these procedures require direct physician supervision, it would be expected that the results be discussed with the patient on the same day of service, and this is already included in the urodynamic reimbursement. Please see the AUGS coding fact sheet on billing for urodynamics for further information.

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I am an NP and do estim. We are coding 97750, 97032 and 51784. The code in question is 51784. Can you tell me under what circumstances this can be billed? We were told it can only be used twice in a lifetime (with Medicare) and is inappropriate to use this code with estim and urodynamics when indeed we do evaluate the muscle function and strength of the pelvic floor.

Per the AUGS Coding Committee, You should report 97032 (Application of a modality to one or more areas; electrical stimulation [manual] each 15 minutes)for electrical treatments that require "constant  attendance" and therefore direct patient-to-provider contact according to CPT. You should report 97750 (Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report,) each 15 minutes for functional performance tests to assess needs and identify problems. You should document the specific test used, describe the data collected and the implication on the patient’s plan of care, as well as decisions made based on the results for each course of therapy. Regarding the use of 51784, (EMG of the anal or rectal sphincter, other than needle, any technique) the code is a diagnostic test code for muscle coordination and therefore would not be utilized except for diagnosis. It is reasonable to report EMG testing at the initial evaluation and after completion of the planned therapy to document change however, it would not typically be used during the therapy sessions as a component of therapy.

The AUGS Coding Committee is not aware a rule that 51784 can only be used twice, specifically. The following information was obtained during our research from the CMS website regarding the codes for further study if desired:

Coding Guidelines

  1. Biofeedback training services are allowable and billable to Medicare Part B when performed on patients in place of service other than hospital inpatients, or skilled nursing facility. Biofeedback training performed in inpatient hospital and skilled nursing facility is billed Medicare Part A.
  2. Biofeedback sessions are limited to the appropriate number of sessions per beneficiary per condition (e.g., up to six sessions over a three-month period).
  3. When performed with biofeedback, the use of EMG CPT codes 51784, 51785, 95860, 95861, 95863, 95864, 95870 and 95872 are covered by Medicare only when the service performed is a totally separate medically necessary service (different ICD-9 code). When an E&M service is performed for the condition treated with biofeedback, it is included in the biofeedback therapy service. 97014 Application of a modality to one or more areas;, electrical stimulation (unattended) 97112 Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. 51784 Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique 51785 Needle electromyography studies (EMG) of anal or urethral sphincter, any technique 95860 Needle electromyography; one extremity with or without related paraspinal areas 95861 two extremities with or without related paraspinal areas 95863 three extremities with or without related paraspinal areas 95864 four extremities with or without related paraspinal areas 95870 limited study of muscles in 1 extremity or no-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters 95872 Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, any/all sites of each muscle studied.
  4. Evaluation and Management services performed on the same day as biofeedback training are covered by Medicare only when the service performed is considered truly separately identifiable (the 25 modifier must be used). When the E&M service is performed for the condition treated with biofeedback training, it is considered included in the biofeedback training service.
  5. List the CPT code that appropriately describes the procedure performed.
  6. Codes 90901 and 90911 do not include a time element. Therefore, time is not a factor when using these codes to identify the service. These codes should be used once to identify all modalities of the biofeedback training performed for that date of service, regardless of time increments or number of modalities performed. For example, if 1-1.5 hours of surface electromyography is spent for neuromuscular assessment and re-education, report for the number of service = one.
  7. List the most specific ICD-9 code to describe the patient's condition that is being treated with biofeedback training.
  8. Biofeedback is not covered by Medicare for treatment of ordinary muscle tension or for psychosomatic conditions.
  9. If Biofeedback devices are provided for home use, they must be billed to the DMERC.

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I removed some granulation tissue from a patient who had a McCall's a year ago. The patient reported a foreign body sensation but the stitch was not visible and was left intact. What code should I use for this in-office procedure? We are considering 58999 and L92.9. There is no charge assigned to 58999, so we are unclear as to what fair market value for this procedure should be.

Per the AUGS Coding Committee and based on the information provided, we would suggest that CPT 17250 (Under Destruction Procedures on Benign or Premalignant Lesions of the Integumentary System) be used as a corollary. Market value is determined by the hospital/insurance agreements and the coding department submits a similar code in these instances.

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A patient has a surgical scar at the vaginal apex and planning surgical revision - would 57000 be an appropriate code for this?

Per the AUGS Coding Committee, this question is a very common question and is also a very difficult question to answer. 57000 is a reasonable code for the described procedure. In order to assign a more specific code with diagnosis, more information would be needed. 57200 could be used if the etiology of the scarring is an immediate response to an injury. 58999 is an “unlisted GYN procedure” code that could be submitted if the etiology of the scarring is difficult to determine and should be saved as a “last resort” code. Remember, if the scarring is being corrected in a prior operative global period, a 78 modifier must be utilized as well.

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My coding office is having trouble with Medicare not recognizing the taxonomy code for FPMRS. Our multi-specialty group has several Ob/Gyns that frequently consult me, but Medicare does not reimburse those visits as consults/new patient visits because they do not recognize Urogynecology as a separate subspecialty. Our commercial contracts are not a problem. Has this been addressed?

Per the AUGS Coding Committee, distinguishing between the same practice or what constitutes a single group can be challenging in a multispecialty group within a single employer structure. Medicare typically reviews tax id numbers and recognizes specialty and sub-specialty designations based upon a two digit code. Providers bill based upon their two digit specialty code. Currently, there is not a unique two digit code for FPMRS. Your question suggests both of you are billing the same ob/gyn two digit code. Additionally, CMS does not recognize consultation E/M services. Also, if there is a call coverage connection between the two physicians, the patient would be considered an established patient by CMS definition. 

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Medicare allowable for DMSO is $450.01 (J1212) but the medicine (cheapest we could find) is $609. How is this possible? How do other practices deal with this?

Per the AUGS Coding committee, they are not in the position to comment on the reimbursement practices of regional payers.  You have correctly identified the the HCPCS code for DMSO is J1212, and as you point out is paid at the rate of $450.01 per unit. The allowable fees for Medicare as set by CMS.  Your only options are to not provide the service, if you feel that it is a financial burden.   Alternatively, you can ask the patient the fill a prescription and bring it to the office, but this is universally unsuccessful. 

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Should the modifiers (eg 26, 51 & 59) be used in combo cases and urodynamic? And how do you code the the following combo case and urodynamic with modifiers? Case 1: Vag hyst (58260), ant & post repair (57265), colpopexy (57283) and sling (87288). Case 2 (urodynamic): 51729, 51741, 51784, 51797, 52000

Per the AUGS Coding Committee:

Case 1: Vag hyst (58260), ant & post repair (57265), colpopexy (57283) and sling (87288).

Vaginal surgeries often involve multiple procedures, some of which can be billed together using modifiers such as -51 or -59. However, more comprehensive codes do exist, and the surgeon should use one code to describe the overall procedure if at all possible. The NCCI initially bundled colporrhaphy with vaginal hysterectomy in 2014. However, due to efforts from AUGS and ACOG, NCCI did modify these pair edits. Colporrhaphy can now be billed with vaginal hysterectomy using a 51 modifier for multiple procedures. Similarly, vaginal apical suspensions, such as 57282 and 57283 can be billed along with vaginal hysterectomy using a -59 modifier, as long as the documentation supports the additional work. NCCI Response to Laparascopic hysterectomy procedure code edits can be found here.  Unfortunately, 57283 cannot be billed together in the same setting as 57265, as the latter bundles the former. In general, surgical procedures that include an enterocele repair can be billed together with apical suspension procedures. 

Assuming that your practice documented a vaginal hysterectomy with an AP repair and enterocele repair, you would bill as follows: 

58260

57265-51

57288-51

For a detailed response to the above question, please refer to the AUGS website. Under the tab “Clinical Practice”, the “Coding” links to many useful coding tools. Specifically, “Vaginal Hysterectomy Coding Update: Claims Eligible for Resubmission on April 1, 2015” explains the use of modiifiers when billing vaginal hysterectomy codes with concomitant prolapse repair codes in great detail.

 

Case 2: urodynamic 51729, 51741, 51784, 51797, 52000

Full urodynamic testing would result in reporting the following four CPT codes:

51741 for complex uroflowmetry

51729 for complex cystometrogram, including measurement of urethral pressure and bladder voiding/flow pressure

51784 or 51785 for the EMG

51797 for the abdominal pressure, whether measured rectally or vaginally

The add-on code 51797 does NOT require any modifier. The modifier 51 would be used with the codes 51741 (complex uroflowmetry), 51784 (EMG) and cystoscopy (52000) to indicate additional procedures. For a detailed description of CPT codes pertinent to urodynamic testing and there use, please please refer to the AUGS website. Under the tab “Clinical Practice”, the “Coding and Reimbursement Resources” links to many useful coding tools. The “Fact Sheets” section includes a detailed fact sheet discussing billing of urodynamic tests.

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Patient had a history of pubovaginal sling in the late 90s with gortex pledgets supporting the periurethra. She had chronic pelvic pain. She had other procedures in the retropubic space and there were dense adhesions.E xcision of the periurethral, retropubic pledget performed vaginally. Dense scarring needed to be taken down taking approximately 2 hours. What would the CPT code be?

Accurate coding is based upon what procedure is performed and documented. In order to provide an accurate response to your coding question, the AUGS Coding Committee would to review the operative report to provide the correct CPT coding. Unfortunately, time is not one of the issues addressed in procedural coding. All of the codes are based on what the “typical” procedure is and the codes are valued for “typical” time allotments.

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Patient with persistent friable (area has tissue looking papillary) urethral caruncle (s/p estrogen therapy, treatment of constipation) undergoes an office biopsy of the urethra. Biopsy performed with lidocaine, suture ligation at base of the caruncle, and tissue removal to pathology. What is the appropriate CPT code? 53200 pulls up on our billing software.

Per the AUGS Coding Committee,

  • 53265 is the CPT code for excision of a urethral caruncle.
  • 53200 is the CPT code for biopsy of the urethra. Your question states you ligated the base of the lesion, implying removal of the lesion

Depending on your note description, you should code as correctly as possible to match the procedure that you performed in the office.

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What is the best code to use total vaginectomy, colpocleisis and cystoscopy for a complete vaginal vault prolapse?

Per the AUGS Coding Committee,  there is no single code answer for this question. The key to accurate coding is to code what was performed. The documentation of the procedure should support the submitted code and is the physician’s protection in case of audit.  For colpocleisis, the code for the basic procedure is 57120. Any additional required procedures are coded with modifiers and are subject to bundling constraints. 57106 and 57110 are the codes for removal of the vaginal epithelium partially and complete. 57106 is the code for partial removal of the vaginal wall and is typically utilized with apical vaginal tissue removal. 57110 is appropriate for total removal of all vaginal epithelium. The operative report should descriptively support the identification method of all of the tissue with its removal. 52000 may be reported with 57110 when appropriate with a modifier.

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If you are doing a post hysterectomy vault prolapse and not making channels, would that be a total removal of the vaginal epithelium (57110) and colpocleisis (57120)? If there is a uterus present and I want to make channels for drainage, would I do a partial removal of epithelium (57106) with a colpocleisis (51720)?

Per the AUGS Coding Committee, 57110 is an obliterative operation that describes complete removal of the vaginal tissue. Typically it is performed with the operative report denoting the division of the vagina into quadrants, the excision of all of the vaginal mucosae, and closure of the underlying tissue in a purse string fashion. No vaginal tissue remains.

57120 is an obliterative procedure done when a patient has an existing cervix/uterus and the vaginal tissue is removed in such a fashion to leave lateral vaginal tissue contiguous with the cervix to allow for drainage.

The two codes would not be coded on the same patient. The codes are two different operations that are both obliterative operations.

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I'm getting rejections for patients I see in an office separate from my private practice. I refer them to my PP for further evaluation & testing for uterine prolapse and SUI. I billed out a E&M service (99214) for OBG, and an E&M with modifier 25 (99214) with a cystoscopy (52000) for my PP. The OBG office is getting paid and the private practice is being rejected. How can I get these processed?

Per the AUGS Coding Committee, they cannot speak directly to rejections from payors, since this will depend upon the specific contracts in place. A detailed analysis would require review of the specific documentation. At first glance, however, it appears that you are billing for the evaluation and management component twice. If you see a patient in one location, and then refer her for a specific procedure (e.g., cystoscopy) in another, there is no “evaluation and management” associated with the procedural visit. That should be coded purely as a procedure. Any counseling and discussion regarding the procedure is contained within the context of the procedure. You should review the details of your contract with the payor in question for details.

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I used a ureteroscope to look at periurethral tunnels left from an old pubovaginal sling. Patient had a retropubic fistula from the vagina to the mons along the old pubovaginal sling track (which used permanent sutures and gortex pledgets). Vaginoscopy with the ureteroscope is not a CPT code. Would I be able to bill and EM for the time since this was an extensive version of an exam?

Per the AUGS Coding Committee, A CPT code does not exist for vaginoscopy with a ureteroscope, and therefore,  this is not a billable service.  There is no CPT code of vaginoscopy.  The closest would be colposcopy of the vagina, but this is performed with a colposcope, and the code description stipulates that the entire vagina is surveyed, which is not what you describe.  Therefore, this would not be an appropriate code either.

Unfortunately, you cannot expect to be paid for procedures that do not have an approved CPT code, as we have previously explained. It would not be appropriate to try to re-bill this as an office visit.

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Is there a document listing common "Unlisted Codes" used in Urogynecology (such as Levator Injection of Botox or certain laparoscopic procedures like LSC VVF repair)? What are people doing in order to get paid or get RVU credit for these unlisted procedures?

Per the AUGS Coding and Reimbursement Committee:  There are no current CPT codes that describe either the procedure of botox injection into the levator ani or laparoscopic vesicovaginal fistula repair, therefore, both procedures are likely to be regarded as experimental by most insurers, and therefore they are not reimbursable.  

You may try using the code 64614, chemodenervation of muscles; extremity(s) and/or trunk muscle(s), for the botox procedure, but most carriers will not reimburse for this.

Some surgeons have used the unlisted laparoscopy procedure, bladder 51999 to code for a laparoscopic approach to vesicovaginal fistula.  You should include a copy of the operative report when submitting this claim.

For additional information concerning the use of unlisted codes, please refer to the AUA Q&A page: https://www.auanet.org/resources/use-of-unlisted-codes.cfm

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I am told that I can't bill for removal of a mesh sling (57287) and placement of a fascial sling (57288) at the same time; i.e. 57287 will bundle with 57288. Is this correct? If so, would the difficulty of digging out a mesh sling justify the -22 modifier for a fascial sling procedure?

Per the AUGS Coding Committee: 57287 describes the removal or revision of a pubovaginal sling. Placement of a second sling is already valued into this service. Therefore it is not appropriate to add a -22 modifier. You cannot use a -22 modifier to bypass the NCCI pair edit of 57287 and 57288.

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What does the 'global period' include for MUS(57288) and how many days before and after the surgery? In general (all surgery) does the global period include the preoperative visit? Can we bill this visit (where we spend a ton of time getting informed consent, patient education, etc) as an office visit and get paid?

Procedure code 57288, sling operation, has a 90 day global. Some commercial companies will pay for a preoperative visit exclusively. This would be considered part of the normal E/M visit with the counseling as part of the visit for the problem that is being coded for CMS. Doing the visit the day before the surgery would be included in the global package as defined by CMS.

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If the global period includes a certain amount of days BEFORE the actual surgery, and we do a lengthy visit w/ the patient for surgical counselling on a date before that time), can we bill for it and get paid? We spend an average of 20+ minutes at the 'preop' visit going over consent, expectations, etc. I'm getting a sinking suspicion that we aren't allowed to get paid for that visit?

90-day Post-operative Period, (major procedures) (This is reproduced from the CMS Website)

One day pre-operative included: Day of the procedure is generally not payable as a separate service, total global period is 92 days. Count 1 day before the day of the surgery, the day of surgery, and the 90 days immediately following the day of surgery.

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What happened w/ TVH reimbursement when performed concomitantly w/ other prolapse repairs (ie w/ 57282, 57283 or 57260)? I used the appropriate -59 & -51 modifiers w/ detailed dictation in the op note as instructed by AUGS. Is this working? Are we getting paid? Did CMS reverse this rule?

Reimbursement has been reported by the membership of the society to be occurring as expected when coded with the appropriate modifier. The best way to ensure reimbursement within your own setting is to evaluate EOB's for your more dominant commercial payers and CMS. That ensures your individual CMS subcontractor is also complying.

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I recently treated a woman with stage 4 prolapse and stress incontinence. I coded appropriately. I was paid for a vaginal hysterectomy, less for vaginal uterosacral colpopexy, less for anterior repair much less for posterior repair and closure of her enterocele and even less for a retopubic TVT sling. Any thoughts about making large cases like this one a two admission process?

Per the AUGS Coding Committee, physicians are obligated to code using the fewest and most appropriate codes. It is considered unacceptable to unbundle two procedures for which a combination code exists. Payment for surgery includes all services estimated to occur during the global period, which is why payment for multiple procedures is reduced.  Typically, the primary procedure – often identified simply because it has the highest RVUs is reimbursed at the contracted rate.  The 2nd thru fifth procedure are each paid at approximately 50% of the stand alone rate.  In the case you presented,  the most appropriate billing combination is as follows:

Vaginal hysterectomy
AP repair  (using the combined code 57260 – unbundling the anterior and posterior repair is not appropriate)
Apical suspension procedure (57283 or 57282)
Pubovaginal sling
 
It is best not to bill additionally for the enterocele repair, as these groups of codes will not allow you to bill separately for the apical procedure.

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With a new patient visit, I may do a straight cath to document void/PVR. I might bill a 99204 (with all criteria met for this E&M) with a 25 modifier. Is this correct coding? Is there specific documentation that I need for the modifier?

Per the AUGS Coding Committee, separate documentation is required for both the E&M visit and the procedure.  The 25 modifier would be attached to the E/M code for the appropriate level of visit.  Specifically, a procedure note is required for the catheterization.  I would suggest that you create a phrase within the EMR such as:  The urethra was prepped with betadin.  A lubricated 12 french catheter was inserted and the postvoid residual urine was collected.

For example:

99204  New Patient visit with Modifier 25

51701  Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine) 

You would then use the appropriate Dx codes to match the E/M and CPT codes you list.  The new patient visit could list the reason patient presents such as Overactive bladder while the CPT code would be designated for her condition such as incomplete bladder emptying.

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What would be the proper codes to use for a trans-vaginal sacrospinous ligament hysteropexy with or without concomitant colporrhaphie(s)?

Per the AUGS Coding Committee:

57282- Colpopexy, vaginal, extra peritoneal approach (sacrospinous, ileococcygeus).

This may be appropriate if the suspension involved the vagina primarily otherwise 58400 is the code for uterine suspension and it does not specify abdominal vs vaginal approach. Note that 58400 is a separate procedure code, which means that it is typically included with other procedures, and can be difficult to be reimbursed when billed with other codes:

57240- anterior colporrhaphy.

57250- posterior colporrhaphy.

57260- combined anterior and posterior colporrhaphy.

57265- A&P repair with enterocele repair. Please note that 57265 cannot be billed with 57282 (or 57283)

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Is 57120 the code for both total colpocleisis and Lefort colpcleisis? Does total colpocleisis have a different code from Lefort colpocleisis? Can cystoscopy 52000-51 be billed if the patient has urinary incontinence or urinary retention diagnosis or is it bundled with both procedures above?

Per the AUGS Coding Committee, a LeFort and Colpocleisis are both synonymous for coding purposes and you should use 57120.  The uterus is in situ and needs to be reduced.  The vaginal epithelium is then closed at the introitus.

One likely does further work such as a posterior colporraphy and perineoplasty pursuant to that to help further obliterated the vaginal canal and reduce vaginal length.

A "colpectomy" or "vaginectomy" is different - this is when the uterus is not in situ.  Various codes outline the latter but one has to be careful to read the full description  as most relate to Oncology procedures with lymph node dissection.

For example:  57110  is complete removal of vaginal wall versus 57111 is Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy).

If the patient has urinary incontinence or some other condition (urgency, frequency, hematuria) and the cystoscopy is done for that purpose, you can bill the 52000 with a 59 modifier (not a 51).  That will 'un-bundle' the 52000.  however, if you simply do a cystoscopy to assure ureteral patency, it will be bundled and not reimbursed.

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Coding Q&A - Mesh

Is a special billing code for mesh excision in the office?

Per the AUGS Coding Committee, "Vaginal excision of mesh, 57295, done in an office setting should be billed with the appropriate EM service. CPT codes for mesh revision or removal include use of anesthesia, vaginal packing, and a post-operative hospital visit with discharge.

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A patient with a retropubic sling had a vaginal mesh excision for midurethral sling erosion. Pathology returned for actinomycosis, so I will perform a robotic assisted laparosopic removal of the retropubic arms of the mesh, since the midurethral portion was previously removed. I will use a procedure similar to a laparoscopic Burch to remove this mesh. What is the CPT code? Is it 11008?

Per the AUGS coding Committee, the code that describes removal of a sling is 57287, regardless of approach. Given that this code most accurately describes what you plan to accomplish, it is the most appropriate to use. The use of the robot would not change or alter the procedural code.

11008 as described by the CMS Vignette: Removal of prosthetic material or mesh, abdominal wall for infection...listing separately in addition to the primary procedure, i.e. an add-on code as noted in the question. The add on is to be used in conjunction with 11004-11006 which describes external genitalia, perineum and abdominal wall. The vaginal wall exposure would not fall into that category and would more adequately fall into the prior mentioned code range for vaginal sling exposure. Though the coding committee understands the work that will be involved with the retropubic removal of mesh and the current CPT codes available could be interpreted in as manner as you described, the committee believes CMS would note the codes are designed for the “typical" patient and the patient in question is not the typical patient.

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A patient had a prior sling with point tenderness and banding at the sling tunnel. She reported vaginal bleeding and her partner felt a foreign object during intercourse. I did an exploration of the sling tunnel and dissected some banding. I did not find any sling and therefore did not do a "removal" or "revision". Do I use code 57287 with 52 modifier or 57000?

Assuming that the case was done vaginally, then it comes down to the diagnosis. If this was being done for presumed exposure, then you would use 57287 (with appropriate modifiers) as it is appropriate to the diagnosis, and describes what was intended to be done. On the other hand, if patient had evidence of outlet obstruction or retention, I would use 53500 since it describes removal of scar tissue (which it sounds like was done) as opposed to 57287 which assumes that a prior MUS was at least encountered. One might make a good case for 57000, although associated with opening the apex of the vagina, the code does not specify the location in the vagina, so it is an appropriate code, and describes what was done.  In summary, if done for exposure, you should code 57287 with appropriate modifiers and if done for obstruction, you would code 53500.

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What code is used for abdominal placement of mesh during sacrocolpopexy?

Per the AUGS Coding Committee, the code for colpopexy, abdominal approach (57280) includes “suspension of vaginal vault, any method” and includes the mesh implant. There is NO add-on mesh/implant code for transabdominal mesh/implants used to treat vaginal prolapse or for sling procedures ( 57267 is only for transvaginally placed mesh).

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Coding Q&A - Office Based Procedures

What code can I use for levator floor injection for pain with lidocaine and or botox?

Per the AUGS Coding Committee, the best code to use for this 000 day global procedure is:

20552 Injection(s); single or multiple muscle trigger point(s); 1-2 muscle groups

20553 Injection(s); single or multiple muscle trigger point(s); 3 or more muscle groups

You must also code separately for the medication injected:

J0585 Injection; onabotulinumtoxinA

S0020 Injection; bupivicaine HCL

J2001 Lidocaine injection

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What is the most proper way to bill visit where a pessary in inserted, including the charge for the pessary itself? We've seen pessary billed via codes A4562 as well as 99070.

The AUGS Coding Committee has put together this Coding Fact sheet for Pessary. Please refer to this fact sheet and let me know if you have any additional questions.

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I wanted to suggest a nurse clinic to change pessaries but was told will not get reimbursed. Is this accurate?

Per the AUGS Coding Committee, Assuming you are asking about pessary services performed by a registered nurse, insurance reimbursement coding is based on the American Medical Association CPT² coding system. Under that system, the only Evaluation and Management (E/M) code that a registered nurse can bill is 99211. CPT defines this code as an “office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician performing or supervising these services.” The patient must already be established in the practice. No other codes can be billed by a RN.

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With the new 2015 CMS coding, I noticed a drop in urodynamic RVUs. My coder told me it's because of the modifiers. Adding the modifers 26, or 51 or 59 decreases the RVUs. For example, in urodynamic: 51729-26 (urodynamic) went from 2.51 to 1.25; 51741-26 (uroflowmetry) went from 1.14 to 0.09; 51784-26 (EMG) went from 1.53 to 0.77; 51797-26 (voiding pressure) went from 0.8 to 0.4. Is my coder right?

 Per the AUGS Coding Committee, the coding committee can’t speak to your institutions prior coding practice. Currently, proper coding allows for reporting 51729 ((2.51 wRVU) complex CMG with calibrated electronic equipment with voiding pressure studies and UPP studies) with 51797 (0.8 wRVU) (intra-abdominal voiding pressure study) as an add-on code, i.e. no modifier is required. Typically, 51784 (1.53 w RVU(Patch EMG study)) is coded with a 51 modifier. The 51 modifier indicates multiple procedures in the same operative session or the same procedure multiple times. Because a portion of the work for the additional procedure is already completed in the base procedure, the 51 modifier identifies only additional work that is completed. It might be viewed as a decrease in RVU’s but it is really an increase of RVU’s above what is already being reported by the base procedure and provides for measurement of additional work being completed. List the most resource intense procedure first and the 51 modifier is applied to all subsequent procedures performed. There is a discount of the wRVU’s and reimbursement due to the shared resources of the base or most resource-intense procedure.

Modifier 26 is the physician component of the professional’s component. The professional’s component contains the technical and physician’s component. By definition there is a discount with the 26 modifier because initial valuation of the code included both the technical and physician’s component.

The 59 modifier is similar to the 51 modifier in its structure of reporting. 59 implies additional work at a different surgical site, different encounter, or a different procedure however, CPT suggests not using a 59 modifier if there is already another established modifier that is appropriate. AAPC lists the 59 modifier as “the modifier of last resort”. It is often used to report a separate E/M code on the same date-of-service as a procedure.

This question provides opportunity for multiple layers of complexity however, the coding committee in its response provided the salient points and directs you to the AUGS website for further information.

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How do you code for bladder instillation of Heparin, Lidocaine and Solumedrol for painful bladder patients?

Per the AUGS Coding Committee: 

The proper CPT code for bladder instillation is 51700, you may also code for the medications used, and the units or amount used: 

Heparin J1644 

Kenalog J3301 

The use of a local analgesic, such as lidocaine or Marcaine is typically not separately reimbursable, and is considered part of the 51700 code. Usually the local anesthesia used is NOT billed as it is considered anesthesia bundled into the procedure.

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I am an OBGYN, fellowship trained and boarded in OBG and FPMRS. I am working part time for a urology group and billing under their tax id. When I get an internal referral from a urology partner in the group and I am seeing the patient for the first time, do I bill a new patient or an established patient E&M code?

Per the AUGS Coding Committee, according to CPT, a new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years.

Distinguishing between the same practice, or what constitutes a single group can be challenging in a multispecialty group within a single employer structure. This may vary from one organization to another. Medicare typically looks at whether there is the same tax id number, and recognizes specialty and sub specialty designations based upon a two digit code. In your case, urology and ob/gyn have separate two digit specialty codes and are obviously different specialties. However, it sounds as if you are employed by the group and are therefore the same practice. We are inclined to answer that this patient is not new to you since you are likely using the same medical records in the office. You would therefore bill all encounters as an established patient, and not a consult or new patient. However, you may want to get further clarity from either ACOG or AUA on this question, or consult with a certified coder.

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For in office electrical stimulation PT, we have been using codes 91122 and 51784. We’ve been billing these codes every visit, and getting reimbursed by Medicare. We discovered a statement from the CMS LCD that these codes should only be billed out at most twice in a lifetime. We also bill codes 97750 and 97032 which are considered PT codes. Are we at risk of violation since we are not using a PT?

Per the AUGS Coding Committee, 91122 and 51784 are both diagnostic study codes for determination of fecal incontinence and urinary incontinence. They are not E-Stim codes for therapy to be used as part of pelvic floor muscle training. Typically, these codes are used for initial diagnosis and possibly after completion of therapy to demonstrate correction.

Stark pertains only to a specific list of "designated health services" that are determined by CPT code. Generally, the services are imaging, including MRI, CT, ultrasound, PET, and nuclear; physical and occupational therapy; radiation therapy; home health; outpatient prescription drugs; parenteral and enteral nutrition; durable medical equipment; prosthetics, orthotics, and supplies; clinical laboratory; and all inpatient and outpatient hospital services. The specific question regarding possible violation within your practice would be best answered by a health-care attorney.

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Does anyone know the best CPT code for a tampon dye test, retrofilling the bladder with dye and placing tampon in vagina?

Per the AUGS Coding Committee, they are not aware of a CPT procedure code that has been developed for the tampon dye test and would probably bill it as an EM code.

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I have been coding PNE as a unit of 2 since I place one on both right and left in the office. My employer is saying that this is incorrect and it should be a unit of 1 with a 50 modifier. Does anyone have experience with this being paid bilaterally?

Per the AUGS Coding and Reimbursement Committee, it is their understanding that if 2 needles are placed in the PNE then the procedure code is listed twice. The modifier is listed as a second procedure similiar to any other multiple procedure option.

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