How to Report Complication Visits Outside Global Package

When evaluating two potential coding options, it’s important to factor in RVUs.

Consider how you accounted for the OBGYN's approach, uterine size, weight, and extent when coding hysterectomies last month. This is only part of the process.

You should also factor in any additional procedures the OBGYN may perform concurrently and determine the appropriate coding for those as well.

Hysterectomy with Stress Incontinence Procedure: Coding Options

When an OBGYN performs bladder and/or urethra fixation for stress incontinence in conjunction with a hysterectomy, there are two coding options to consider, depending on the fixation technique used.

Abdominal Approach Coding

For an abdominal approach, the appropriate code is 58152:
(Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy [e.g., Marshall-Marchetti-Krantz, Burch]).

Vaginal Approach Coding

For a vaginal approach, use code 58267:
(Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control).

Hysterectomy with Vaginectomy: Appropriate Coding Options

Hysterectomies involving partial or total vaginectomies (colpectomies) require specific codes.

Open Hysterectomy with Vaginectomy

If the OBGYN performed an open hysterectomy with a partial vaginectomy, the appropriate code is 58200:
(Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s)).

This code accounts for the removal of the uterus along with the partial vaginectomy. It may also include removal of some parametrial tissue, typically performed when endometrial cancer has spread to the cervix or parametrium.

Radical Procedures with Vaginectomy

Codes 58210 and 58548 also apply in cases involving radical procedures that include the removal of parametrial tissue and a vaginectomy.

• Code 58210: (Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s)).
• Code 58548: (Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed).

These codes encompass a vaginectomy, specifically the removal of the upper one-third of the vagina, as part of the radical procedures.

Vaginal Approach Coding

If the OBGYN performed the procedure via a vaginal approach, the following codes would apply:

• Code 58275: (Vaginal hysterectomy, with total or partial vaginectomy)
• Code 58280: (Vaginal hysterectomy, with repair of enterocele)
• Code 58285: (Vaginal hysterectomy, radical (Schauta type operation))

Hysterectomy with Lymph Node Sampling: Key Codes to Use

When an OBGYN performs para-aortic and pelvic lymph node sampling, they conduct a lymph node biopsy. This can only be done through an abdominal approach during a hysterectomy. The appropriate code for this procedure is 58200. This service is also referred to as a "modified radical" abdominal hysterectomy and typically includes a partial vaginectomy.

If the OBGYN performs a bilateral pelvic lymphadenectomy along with para-aortic lymph node sampling, the correct codes are:

• 58210 for the abdominal approach
• 58548 for the laparoscopic approach

Ovarian or Endometrial Cancer: Additional Coding Options

In cases of ovarian or uterine cancer, there are additional codes to consider, depending on the specifics of the procedures performed. These codes include:

• 58951: (Resection (initial) of ovarian, tubal, or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy)
• 58953: (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy, and radical dissection for debulking)
• 58954: (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy, radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy)
• 58956: (Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy)

Enterocele Repair: Correct Codes for Vaginal Hysterectomy

Enterocele repair codes are used in conjunction with hysterectomies. For a vaginal approach, the following codes apply:

• 58263: (Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s), with repair of enterocele)
• 58270: (Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele)
• 58280: (Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele)
• 58292: (Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele)
• 58294: (Vaginal hysterectomy with repair of enterocele)

Note: A vaginal hysterectomy with an abdominal enterocele repair does not have a combination code, and this type of procedure is generally not performed by OBGYNs.

Tackle This Hysterectomy Scenario: Coding Breakdown

Scenario: How should you code a vaginal hysterectomy with a uterus weighing less than 250 grams, without the removal of tubes and ovaries, combined with enterocele repair and colpourethrocystopexy?

Answer: You have two coding options.

Option 1:

You can report the vaginal hysterectomy with enterocele repair using 58270. Additionally, for the simple anterior vesicourethropexy, use 51840 (Anterior vesicourethropexy, or urethropexy [e.g., Marshall-Marchetti-Krantz, Burch]; simple). The National Correct Coding Initiative (NCCI) allows for this code combination, and it's a better choice in terms of reimbursement.

Option 2:

Alternatively, you could report the vaginal hysterectomy with colpourethrocystopexy using 58267 (Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy [Marshall-Marchetti-Krantz type, Pereyra type], with or without endoscopic control) and the vaginal enterocele repair with 57268 (Repair of enterocele, vaginal approach [separate procedure]).

Work Relative Value Units (RVUs) Comparison:

• Option 1:
  • 58270: 15.30 RVUs
  • 51840: 11.36 RVUs
  • Total: 26.66 RVUs
• Option 2:
  • 58267: 18.36 RVUs
  • 57268: 7.57 RVUs
  • Total: 25.93 RVUs

Given the higher RVUs in Option 1, reporting the first option is more beneficial from a reimbursement perspective.

Additional Scenario: Postpartum Visit for Hemorrhoid

Following the delivery, the patient experiences prolonged pain and irritation from a hemorrhoid. The OBGYN treats the thrombosed hemorrhoid by incising it during an office visit two weeks postpartum. 

Later, the OBGYN rechecks the patient at the six-week postpartum visit.

Coding for this patient visit

• For the office visits, you’ll report 99212 (Office or another outpatient visit for the evaluation and management of an established patient, typically 10 minutes face-to-face) for routine follow-up visits and 99213 (Office or other outpatient visits for the evaluation and management of an established patient, requiring a medically appropriate history/examination and low-level decision making) for more detailed visits (e.g., for the thrombosed hemorrhoid incision).

Report the Appropriate Preeclampsia Code

When coding for preeclampsia, you will select the correct code based on the documentation and the specific trimester of pregnancy:

• Mild to moderate pre-eclampsia:
  • O14.00 (Unspecified trimester)
  • O14.02 (Second trimester)
  • O14.03 (Third trimester)
• Severe pre-eclampsia:
  • O14.10 (Unspecified trimester)
  • O14.12 (Second trimester)
  • O14.13 (Third trimester)
• Unspecified pre-eclampsia:
  • O14.90 (Unspecified trimester)
  • O14.92 (Second trimester)
  • O14.93 (Third trimester)

Additionally, for hemorrhoids in the puerperium, you will report O87.2.

Best Timeframe to Submit Your Claim

You have two options for submitting your claim, depending on the situation:

Option 1: After Delivery (Most Recommended)

Many coders recommend submitting the claim after delivery. This is because the extent of complications and the extra work involved for the OBGYN cannot be fully determined until the patient delivers. Waiting until after delivery helps ensure accurate coding for any additional visits or services beyond the global OB package. To avoid losing revenue, it’s essential to have a system in place to review patient records carefully and ensure that all additional charges are captured.

Option 2: During Pregnancy (If Timely Filing Is a Concern)

If you need to submit claims while the patient is still pregnant, be aware that some payers may deny the claim since the patient has not yet delivered. Although the diagnosis code may correctly reflect the complication, many payers deny visits if they fall within the antepartum period. If this occurs, you can appeal the denial after the delivery without being subject to the payer’s timely filing rules. However, if the patient delivers earlier than expected, you may have to return any overpayments if the total number of antepartum visits does not exceed the global OB package.

Red Flag

Some payers have specific guidelines for services outside the global package. It’s crucial to check with your payer to determine which option to choose when submitting claims.

Additional Considerations

The term “high-risk” can apply to a complication in the current pregnancy or to concerns based on the patient’s medical history. Payers typically recognize complications but do not allow additional reimbursement for concerns that are not currently affecting the pregnancy, such as a worry about future complications based on history.

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