Coding and Compliance: Guarantee Proper Billing for Pelvic Examination under Anesthesia



Plus, know more about the colpopexy coding updates

CPT code 57410 is a pelvic examination under anesthesia. And it says other than local, meaning that the patient is on the general spinal or possibly epidural anesthesia. This code 57410 is only for the female. But you cannot use this code when billing any other CPT procedural codes because this code is included in all other urological female or urogynecological codes. Read these expert tips and strategies provided by our coding expert in a medical coding conference to know more.

However, we have another code, the 45990 which is for an anorectal examination bimanual pelvic examination, again, requiring anesthesia, general spinal or the epidural anesthesia. This is a diagnostic study. It can be used in a male or female.

Now, this study includes anoscopy and a rigid proctoscopy to procedures that the urologist and the urogynecologist rarely do. So if you're going to use this code for your anorectal examination and bimanual pelvic under anesthesia, add modifier -52 to indicate that this is a reduced procedure and you did not perform the anoscopy or the proctoscopy. And remember, this code also includes the bimanual pelvic examination. You can bill this code with many procedures to have cleaner medical coding and billing claims.

Colpopexy: The suspension of a vaginal Apex

Now, we’d like to talk about the various approaches. We have a vaginal approach. Now, this vaginal approach is payable by Medicare when it is performed with a total abdominal or a total vaginal hysterectomy.

We have the code 57282 colpopexy, vaginal procedure, extraperitineal approach using the sacrospinous ligaments or the iliococcygeus muscle group. And this code, the 57282 includes an enterocele repair.

We also have another vaginal approach colpopexy, the 57283 which is an intraperitineal approach using the ureterosacral ligaments or a lobatum myorrhaphy. Now, this code, the 57283, an intraperitineal colpopexy has been called a mccol colpopexy. And this includes an enterocele repair and also the obliteration of the culdesac.

Now, in these repairs, you may use mesh or an implantation of mesh to secure the repair. Code 57267 is not separately payable with these two above procedures.

Let’s talk about abdominal and laparoscopic approaches to colpopexy. We have the medical coding option57280 colpopexy abdominal approach. And remember, this is also payable as a secondary procedure by Medicare when performed with the total vaginal or abdominal hysterectomy. It includes the mesh if you use the mesh, but the mesh is not payable with this code. This procedure, the abdominal colpopexy has been called the Moskowitz colpoplasty.

We also have the code, 57425. And this is a laparoscopic surgical colpopexy payable also as an additional procedure if you do a laparoscopic supercervical hysterectomy or a laparoscopic assisted vaginal hysterectomy or a laparoscopic total hysterectomy.

This procedure as the above procedure includes the mesh, if it is used in the repair. So, our expert suggested in the medical coding conference that you should not code or bill separately for the mesh in these procedures, in fact, in any of the colpopexy procedures.

For more urogynecological medical coding training online, visit our coding and compliance page.

Our Accreditation Partners
Facebook Twitter Linkedin Youtube RSS Feeds Google Plus