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Ob-Gyn Coding Alert

Case Study:
Choosing the Best Reimbursement Code for an Optional Hysterectomy

Editors Note: A goal of all coding should be to accurately report the services provided to the patient with precise justification. However, in some cases, more than one correct coding option is possible. This case considers two options and explains why one may provide greater reimbursement than the other. This case also considers the question of medical necessity for what may appear to be an optional hysterectomy. If you have a case youd like to submit for consideration, please send it via fax, email or mail.

The patient is a 50-year-old nulligravida female who has been treated medically for stress urinary incontinence for almost a year, with little success. She is considering having the urinary incontinence treated surgically, but before she has decided, she presents in the office with right abdominal cramping. She states that both her mother and her mothers sister developed ovarian cancers in their early 60s and she is quite worried that her pain may be related to that problem. The patient was on oral contraceptives for six years during her life. Pelvic exam at this visit reveals a right ovarian mass. An ultrasound is performed in the office, which shows a 3 cm right ovarian cyst that is possibly endometrial in nature. After extensive counseling regarding management of the cyst, the likelihood of her developing ovarian cancer and the failure of medical treatment to satisfactorily alleviate her stress urinary incontinence, she elects to proceed with hysterectomy and BSO and a pereyra urethropexy.

At the time of surgery (two weeks later), the physician confirms a chocolate cyst of the right ovary. Inspection of the posterior cul-de-sac reveals a moderate enterocele that is repaired using high plication of the uterosacral ligaments and a McCall plication of the enterocele itself.

Terminology and Procedures

This patient is found to have several problems that justify her surgery. First, her abdominal pain is being caused by an ovarian cyst that is more correctly identified as ovarian endometriosis, ICD-9 code 617.1. Endometriosis occurs when a small portion of the tissue lining the uterus (the endometrium) begins to grow in another part of the body. Up to 10 percent of women experience some form of endometriosis. In most cases, this growth develops in the pelvic area, on the ovaries, the lining of the pelvic cavity, ligaments or the fallopian tubes. As these growths are made of endometrial tissue, they usually behave like the endometrium, responding to the hormones of the menstrual cycle. Each month, they build up tissue and slough it off. As a result, pain, internal bleeding, inflammation, cysts and scar tissue can develop in the affected areas. [...]