Think fast: how quickly can you name the different components of hysterectomy, hysteroscopy, and laparoscopy services? Chances are coding for these and other gynecological services can trip you up, as they often do even the most seasoned coder. Unless you’re well-versed in best-practice coding, you could be losing money every time you bill.
With over 25 years of coding experience, Lori-Lynne A. Webb has dozens of tips and tricks to share to help your gynecology practice get paid. In her live webinar with ProfEdOnDemand, “Coding, Clinical Documentation & Medical Necessity for Gynecologic Surgery,” Webb outlines the concepts you and your staff need to understand to conquer the nuances of gynecological coding.
Similar Symptoms, Different Procedures
Confusion between gynecological procedures is common because different procedures—hysterectomy, hysteroscopy and laparoscopy—can be used to treat many of the same symptoms, including:
- Dysfunctional bleeding
- Painful fibroids
- Endometriosis
When coding, use a few key tips and tricks to differentiate quickly between each procedure. First, let’s take a quick look at what each procedure does:
- Hysterectomy: A surgical procedure to remove the uterus. This procedure requires a long recovery (typically 6-8 weeks). There are four main types of hysterectomy, based on how much of the reproductive system is removed, along with three ways a hysterectomy can be performed.
- Hysteroscopy: A minimally-invasive procedure which allows the physician to see the endometrium, or lining of the uterus. A hysteroscopy can be either diagnostic (evaluating or assessing abnormalities in the uterus) or operative (correcting faults found). Both diagnostic and operative can be performed on the same day.
- Laparoscopy: A minimally-invasive procedure to view the abdominal and pelvic organs. Laparoscopies can also be diagnostic or operative, and can include robotic aid or not. Physicians can perform a type of hysterectomy, known as laparoscopic hysterectomy, or they can also remove ovarian cysts or tubal ligation.
Eyes on the suffixes: In surgical procedures, “ectomy” indicates the removal of a part of the body, while “oscopy” indicates the viewing of a set of organs, normally with a scope. Therefore, look first in the documentation to see if the physician merely evaluated or actually removed. From there you’ll be able to follow the other tricks to make your coding even easier.
3 Focus Areas to Guide Coding
With documentation for gynecological coding, you’ll need to focus on three main areas:
- What was the purpose of the procedure (diagnostic or operative)
- Where anatomically was the focus of the procedure (uterine or abdominal)
- Where was the starting point of the procedure (cervical or abdominal)
Determining diagnostic or operative first allows you to rule out a hysterectomy if the procedure was purely diagnostic. If you can rule out a hysterectomy, determining a uterine or abdominal focus would lead you to correctly select between hysteroscopy and laparoscopy – hysteroscopes examine the uterine lining via access through the cervix, while laparoscopes are inserted through the abdomen and examine the organs in that area.
Prioritize to Select the Right Code
One final note about laparoscopy procedures: When operative, a laparoscopy can involve removal of the uterus. This is why you’ll note CPT® codes such as 58541: “laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less.” Don’t let this trip you up – although this procedure is removing the uterus, since it’s minimally invasive you would count it as a laparoscopy first and a hysterectomy second. For more invasive procedures, use these traditional hysterectomy codes.
Quick Note: Before submitting a claim, always double-check which codes can be bundled based on the provider, as well as each provider’s rules for submission of various CPT® codes. Don’t let the differences between private payer and Medicare rules keep you from submitting fool-proof claims.
Gynecological coding is one area where you’ll have to let your attention-to-detail magic shine, says Web. Say goodbye to coding confusion with these tips and tricks to not only feel more confident in your skills, but to also keep that steady stream of reimbursement coming your way.
