Vol. 17 •Issue 12 • Page 11
Coding Corner
Coding the Female Genital System
When two procedures are performed, add modifier 51 to the second professional code assigned.
Case Study One
Pre- and postoperative Diagnosis: Infertility
Procedure Performed: Operative laparoscopy; egg retrieval for gamete intra-fallopian transfer
Anesthesia:General endotracheal
Operative Findings: Bilateral multiple follicular development. The uterus was moderately enlarged with a 4 cm anterior lower uterine segment fibroid on the left and a 2 cm subserosal fibroid in the posterior fundal region. Otherwise, the uterus was mildly enlarged with no evidence of other fibroids. The surface had multiple film adhesions and the ovaries were slightly fixed bilaterally. They were maximally enlarged from ovarian stimulation. The left and right fimbria were normal. The left tube had some peritubal adhesions.
Operative Technique: The patient was prepped and draped in the low Allen stirrups in the usual fashion for gamete intra-fallopian transfer surgery. The transvaginal ultrasound probe and the #16 gauge aspiration needle were used to aspirate the left ovary completely. The right ovary was not amenable to transvaginal aspiration, and the laparoscope was utilized for laparoscopic aspiration.
The umbilicus was preinjected with 0.25 percent Marcaine with epinephrine. A 5 mm trocar was placed in the usual fashion, and intraperitoneal localization was visualized prior to carbon dioxide insufflation.
Two 5 mm trocars, one suprapubic and one left lateral were placed in the usual fashion. The right ovary was manipulated and a #16 gauge aspiration needle was utilized to further aspirate the remaining follicles on the right. Eleven eggs in total were obtained. The gamete intra-fallopian transfer catheter was utilized to inject one egg into the left tube in the usual fashion. The umbilicus was closed with 2-0 Vicryl suture, and the gas was allowed to escape from the abdomen. The remaining incision sites were closed with Steri-strips and Benzoin in the usual fashion. The estimated blood loss was 100 cc. There were no complications. The patient was taken to the recovery room in stable condition.
ICD-9-CM DIAGNOSES:
Pre- and postoperative: Infertility
628.9 Female infertility of unspecified origin
CPT CODE ASSIGNMENTS AND RATIONALE
In the first portion of this procedure, the physician removed the egg(s) from the ovary laparoscopically. To assign the code for this portion of the procedure, refer to the term Oocyte in the index. As it was a removal, go to terms Retrieval and In Vitro Fertilization. The code listed is 58970. After checking the description of code in the manual, you will see that this is the correct code.
In the second part of the procedure, the physician transferred the egg(s) into the fallopian tube. To appropriately assign the code for this portion of the procedure, go to the term Gamete Transfer in the Index. Again, you will see In Vitro Fertilization listed below the main term followed by code 58976. After reading the description in the manual, you will see this is the correct code.
Because multiple procedures were performed, you will add modifier 51 to the second professional code assigned.
Facility code assignments:
58970 Follicle puncture for oocyte retrieval, any method
58976 Gamete, zygote or embryo intra-fallopian transfer, any method
Professional code assignments:
58970 Follicle puncture for oocyte retrieval, any method
58976-51 Gamete, zygote or embryo intra-fallopian transfer, any method
Case Study Two
Preoperative Diagnosis:Polymenorrhea and menorrhagia, rule out endometrial polyp
Postoperative Diagnosis:Polymenorrhea and menorrhagia, benign endometrial polyp
Procedure Performed:Hysteroscopy, D&C
Anesthesia:General
Operative Technique:The patient was taken to the operating room and placed in the dorsal supine position, and general anesthesia was undertaken. She was then placed in the dorsal lithotomy position, prepped and draped in a normal fashion. A weighted speculum was placed in the posterior vagina, the cervix was grasped with a tenaculum and the uterus was sounded to 9 cm. The cervix was dilated to 6 mm without problems. The hysteroscope was placed with lactated Ringer’s for insufflation and the above findings were noted, which were basically negative. Sharp curettage was then done of the uterine contents with a small amount of material removed. The uterus was sounded to 9 cm.
It should be noted that the uterus on exam was anteverted, irregular, about 6 to 8 weeks in size. There was good descent with the tenaculum, therefore, a vaginal hysterectomy could be attempted if ever needed.
The tenaculum was taken off the anterior cervix and the patient went to recovery in stable condition.
ICD-9-CM DIAGNOSES:
Preoperative: Polymenorrhea and menorrhagia, rule out endometrial polyp
626.2 Excessive or frequent menstruation
Postoperative: Polymenorrhea and menorrhagia; Benign endometrial polyp
626.2 Excessive or frequent menstruation
621.0 Polyp of corpus uteri
CPT CODE ASSIGNMENT AND RATIONALE
The surgeon dilated the cervix first then inserted the hysteroscope. Once the scope was in place, the curettage was performed. Go to the index and find the term Dilation and Curettage, which is followed by the term Hysteroscopy. The code listed is 58558. After reading the description in the manual, you will see this is the correct code.
The following code would be assigned for both the facility and professional component:
58558 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C
Peggy Hapner is manager of the HIM consulting division at Medical Learning Inc. (MedLearn®), St. Paul, MN.
