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Ob-Gyn Coding Alert

Get Paid for Pessary Insertion, But Leave Supply to Patient

You can avoid the pessary pitfalls of low reimbursement and uncertain coding by writing the patient a prescription and allowing her to seek payment for the supply while you bill for the device's insertion. In the past, CMS classified pessaries as orthotics and reimbursed for them only through the Durable Medical Equipment Regional Carriers (DMERCs), says Judy Richardson, MSA, RN, CCS-P, a senior consultant at Hill and Associates Inc., a coding consulting firm in Wilmington, N.C. "In 2002, the payment methodology shifted to the Part B carriers and is now reimbursed under the Physicians Fee Schedule," she adds. Although Medicare simplified pessary billing by placing everything under the Medicare carriers' jurisdiction, the limited number of codes can make pessary supply, insertion, cleaning and reinsertion for Medicare patients one of the most-vexing coding problems for ob-gyns. A pessary is a ring-shaped device placed in the vagina to support a displaced or prolapsed vagina or uterus. Weakened muscles and ligaments that hold the uterus in place cause the prolapse. Multiple vaginal deliveries, obesity, hormonal changes or old age can cause the weakening. Consequently, ob-gyns treat a large number of Medicare patients for the condition. A pessary is the most common and occasionally the only nonsurgical option for treating advanced uterine prolapse. The device must be removed and cleaned approximately once each month. Coding the Pessary Supply Because Medicare considers pessaries both a supply and an orthotic, you should report them using HCPCS codes:

A4561 Pessary, rubber, any type
A4562 Pessary, non-rubber, any type. You are more likely to use A4562 because it represents silicone pessaries. Women fitted with silicone, rather than rubber, pessaries generally have fewer allergic reactions to the material. In addition, Medicare reimburses for A4561 (about $17) much lower than for A4562 (about $44), depending on where you practice. Because the reimbursement for the pessary supply is usually lower than the price charged by manufacturers, many ob-gyn practices use the option of providing the patient with a prescription to purchase the pessary directly from the supplier and bring it to the office for insertion, Richardson says. Medicare reimbursement is so low for pessaries because the law requires fees to be determined by using the average Medicare payment from 1986 and updating it by an annual factor every year, Richardson explains. In 1986, ob-gyns used mostly rubber pessaries, and the fees were based on these payments. CMS now devises the payments to reflect the different types of pessaries. The agency is aware that the reimbursement does not truly reflect the cost of the device and has informed providers that it is looking into the situation. Sue Dooley, office manager for Pinelli Medical Practice in Jupiter, Fla., contacted her Medicare [...]

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