Reproductive, Intersex Surgery, Female Genital System, and Maternity Care and Delivery List

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Reproductive, Intersex Surgery, Female Genital System, and Maternity Care and Delivery

CHAPTER Chapter Topics
Reproductive System Procedures
Intersex Surgery
Female Genital System
Maternity Care and Delivery

Learning Objectives
After completing this chapter you should be able to
1

Describe reproductive services

2

Report reproductive services

3

Report intersex surgery services

4

Understand the format of the Female Genital System subsection

5

Identify elements of component coding with Female Genital System codes

6

Define the critical terms in maternity and delivery services

7

Define services in the global maternity and delivery package

8

Understand the format of the Maternity Care and Delivery subsection services

9

Demonstrate the ability to code the Female Genital and Maternity Care and Delivery subsection

REPRODUCTIVE SYSTEM PROCEDURES

The Reproductive System Procedures subsection (55920) is located after the Male Genital System subsection and consists of only one code

...

Code 55920 reports the placement of needles or catheters into the pelvic organs and/or genitalia (except prostate) for the subsequent interstitial radioelement application (brachytherapy)

...

This procedure is performed with the patient anesthetized

...

The surgeon examines the diseased areas to determine the area(s) that require treatment

...

A template device is inserted into the vagina and positioned over the areas to receive the radioelement insertions

...

The number and depth of the needles or catheters varies depending on the area to be treated, but typically 32 flexiguide catheters are inserted

...

This code is not used to report radioelement application for the prostate, which is reported with 55875

...

Insertion of a vaginal ovoid brachytherapy system is a common type used to treat cervical cancer and is reported with 57155

...

A Heyman capsule indicated in the parenthetical statement following 55920 directs the coder to 58346 when reporting Heyman capsule insertion

...

A Heyman capsule was a method of manual loading that was used in the early days of brachytherapy

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The physician would manually insert the capsule into the treatment area, which necessitated the physician being in contact with the radioactive source

...

The newer methods of brachytherapy are safer as the radioelements are inserted via catheters, thus reducing the exposure of health care providers

...

INTERSEX SURGERY
The Intersex Surgery subsection (55970, 55980) is located before the Female Genital Surgery subsection and contains only two codes: one for a surgical procedure to change the sex organs of a male into those of a female and one to change the sex organs of a female into those of a male

...

These specialized procedures include a series of procedures that take place over an extended period of time

...

The procedures are performed by physicians who have special skills and training

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The procedure for changing male genitalia into female genitalia involves removing the penis but preserving the nerves and vessels intact

...

These tissues are used to form a clitoris and a vagina

...

The urethral opening is shifted to be in the position of that of a female

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The surgical procedure for changing the female genitalia into male genitalia involves a series of procedures that use the genitalia and surrounding skin to form a penis and testicle structures into which prostheses are inserted

...

FEMALE GENITAL SYSTEM

The Female Genital System subsection (56405-58999) is divided according to anatomic site, from the vulva up to the ovaries (Fig

...

The anatomic sites are then divided on the basis of category of procedure (i

...

, incision, excision, destruction)

...

Codes for in vitro fertilization are located at the end of the subsection

...

F I G U R E 2 5 - 1
A, Female genital system

...

B, Anterior view, female genital system

...

C, External female genital system

...

D, Parts of vulva

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Fallopian tube (oviduct)
Corpus uteri
Cervix uteri
Rectum
Uterine tube
Fundus of uterus
Ampulla
Urinary Ovary bladder Infundibulum
Vagina
Cervix and cervical canal
Vagina
Urethra AB
*Mons pubis
Urethra
Ovary Isthmus
Symphysis pubis
Clitoris
Ligament of ovary
Body of uterus and uterine cavity
with fimbriae
*Labia majora
*Labia minora
Introitus
Bartholin's glands
Perineum *Parts of the vulva
D
*Bulb of vestibule
*Vaginal orifice
*Bartholin's glands
*Parts of the vulva

The subsection has a wide variety of codes for minor procedures that are performed in a physician's office as well as for major procedures that are performed in a hospital setting

...

It is important to read the descriptions of the codes as well as the notes to avoid unbundling in this subsection

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For example, if a total abdominal hysterectomy was performed as well as a bilateral oophorectomy (removal of ovaries), only 58150 would be reported because the code description includes the statement "with or without removal of ovary(s)

...

" Bundled into the code are both the abdominal hysterectomy and a bilateral oophorectomy

...

There are many screening (well woman) services provided, such as screening mammography, Pap tests, and pelvic examination, in addition to colorectal cancer screening and bone mass measurements

...

In this text, these services are reviewed in the chapter that refers to the codes that would be submitted for the services

...

For example, mammography is in Chapter 28, Radiology

...

Vulva, Perineum, and Introitus
There is a repeated note in the Vulva, Perineum, and Introitus subheading (56405-56821) indicating procedures performed on the Skene's glands are not reported using codes in the Female Genital System subsection but instead are coded using Surgery section, Urinary System subsection codes

...

That is because Skene's glands, also known as para-urethral ducts, are a group of small mucous glands located near the lower end of the urethra and are part of the urinary system

...

Procedures involving Skene's glands are, therefore, reported using Urinary System codes (53060 or 53270)

...

Incision

...

...

The vulva includes the following parts: mons pubis, labia majora, labia minora, bulb of vestibule, vaginal orifice or vestibule of the vagina, and the greater (Bartholin's gland) and lesser vestibule glands (see Fig

25-1, C and D)

...

When the code description indicates the incision and drainage of an abscess of the vulva, the code reports an abscess of any of those anatomic areas

...

For example, if a medical record indicates "an incision and drainage of an abscess of Bartholin's gland," you must know that Bartholin's gland is considered a part of the vulva, so the code will be located in that subheading

...

Destruction

...

...

Destruction of lesions of the vulva, perineum, or introitus can be accomplished using a variety of methods—laser surgery, cryosurgery, electrosurgery, or chemical destruction

Destruction codes are divided on the basis of whether the destruction is simple or extensive, although the code description does not define simple or extensive

...

Complexity is based on the physician's judgment of complexity, and the complexity will be stated in the medical record

...

Excision

...

...

The first two codes (56605 and 56606) in the Excision category are for biopsies in which the physician takes a tissue sample by removing a piece of tissue with a scalpel or punch

The area to be biopsied is anesthetized with local anesthetic before the biopsy is performed

...

The physician may suture the area or use clips for closure

...

The local anesthesia and closure are included in the package of an excision code, so be careful not to unbundle and report these separately

...

The codes are also divided on the number of lesions, one and each additional lesion

...

When using the additional lesions code, be certain to specify the number of lesions biopsied by listing the number of units on the CMS-1500 form in Block 24-G

...

CAUTION

Destruction is not excision

Destruction is obliteration or eradication

...

Excision is removal

...

With destruction no tissue is removed, as the tissue is destroyed

...

There is no pathology report after a lesion has been destroyed because there is nothing for the pathologist to analyze

...

CODING SHOT
If the excision is of a lesion of the skin of the genitalia, report the service with 11420-11426 (Excision of benign lesion) or 11620- 11626 (Excision of malignant lesion)

...

Vulvectomy is the surgical removal of a portion of the vulva

...

Usually a vulvectomy is performed to treat a malignant or premalignant lesion

...

The following definitions apply to the vulvectomy codes (56620-56640) and describe the extent and size of the vulvar area removed during the procedure

...

EXTENT
Simple

skin and superficial subcutaneous tissue
Radical skin and deep subcutaneous tissue


SIZE
Partial less than 80%
Complete greater than 80%

The vulvectomy codes are divided on the basis of these definitions of extent and size

The extent and size are stated in combination

...

For example, simple partial vulvectomy describes a superficial subcutaneous tissue (extent) removal of 78% (size) of the vulvar area

...

Bundled into the codes is usual closure, but if plastic repair is required, you would report the repair in addition to the procedure

...

The operative report will indicate the extent of the procedure and the closure

...

CODING SHOT
There are two labia: labia minora and labia majora (Fig

...

A partial vulvectomy (less than 80%) pertains to leaving at least 20% of the vulvar area

...

The more radical procedures involving the vulva are usually performed because of a demonstrated malignancy, and more extensive removal takes place

...

This radical removal can include the removal of deep lymph nodes, saphenous veins, ligaments, or large amounts of tissue from the lower abdomen or even from the thigh

...

The procedure may also be performed bilaterally, so don't forget to add modifier -50 when reporting a bilateral procedure

...

CODING SHOT
Most payers do not make a reimbursement adjustment for bilateral procedures of the vulva

...

For example, Medicare does not make an adjustment

...

You must review each payer's guidelines to determine how to submit this code

...

Repair

...

...

The procedure codes in the Repair category (56800-56810) describe plastic repair of the vulva, perineum, or introitus

Plastic repair of the introitus is surgical repair of the opening of the vagina

...

The extent and nature of the procedure are determined by the defect being repaired and varies greatly from patient to patient

...

Clitoroplasty is surgical reduction of a clitoris (Fig

...

25-3) that has become enlarged due to an adrenal gland imbalance

...

Perineoplasty is plastic repair of the perineum, usually to provide additional support to the perineal area

...

Vagina
The Vagina subheading includes the code range 57000-57426

...

Colpotomy (57000-57010) is cutting into the vagina to gain access to the pelvic cavity

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The procedure is performed to explore the pelvic cavity or to drain a pelvic abscess

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Colpocentesis (57020) is the insertion of a long needle (puncture) attached to a syringe through the back wall of the vagina to gain access to the peritoneal cul-de-sac—the area between the uterus and the rectum—to drain fluid

...

If the colpocentesis is a part of a more major procedure, you do not report it separately, as it is considered to be bundled into the more major procedure

...

Note that 57020 has "(separate procedure)" after it to designate colpocentesis as a minor procedure that is reported only if it is the only procedure performed of the area

...

Destruction

...

...

As with the destruction codes for the vulva, the destruction codes (57061, 57065) for the Vagina subsection are divided on the basis of whether the destruction was simple or extensive, in the judgment of the physician

Any method of destruction is acceptable for assignment of these codes

...

Excision

...

...

The Excision category of the Vagina subsection contains codes (57100-57135) for reporting the services of biopsy, vaginectomy (removal of part or all of the vagina), colpocleisis (closure of the vaginal canal), and cyst/ lesion removal

The vaginectomy codes are divided according to the extent of the procedure—partial or total—and the extent to which tissue and adjacent structure(s) are removed

...

Introduction

...

...

The Introduction category (57150-57180) contains codes for vaginal irrigation

Also included is the insertion of a tandem and/or vaginal ovoids for brachytherapy

...

The tandems and/or vaginal ovoids are internal implants that contain a radioactive substance and are often used in the treatment of cervical cancer, as illustrated in Fig

...

A tandem is a small, hollow metal tube that is inserted through the vagina into the uterus (intrauterine tandem)

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Vaginal ovoids are small metal cylinders that are placed into the vagina and positioned against the cervix (intravaginal ovoid)

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The implants then deliver a concentrated dose of radiation to the site of the tumor

...

Other codes in the Introduction category report the insertion of a support device (pessary, Fig

...

25-5), diaphragm, or cervical cap (to prevent pregnancy)

...

and packing of the vagina (for vaginal hemorrhage)

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Pessaries are used for vaginal prolapse

...

The pessary and diaphragm/cervical cap are not included in these Introduction codes

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The supply of these devices would be reported using code 99070, supplies, or a HCPCS code (e

...

, A4561)

...

Repair

...

...

The Repair category (57200-57335) is rather extensive, as the possible forms of repair of the vagina are many

A note in parentheses, "(nonobstetrical)," sometimes follows the code description in the Female Genital System subsection because if the procedure was performed as a part of an obstetric procedure, you would use a code from the Maternity Care and Delivery subsection

...

A surgeon performs a colporrhaphy to strengthen an area on the wall of the vagina that is weak by pulling together the weakened vaginal area with sutures

...

Excess tissue can also be removed to tighten the area

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The reinforcement might be performed for several reasons, but it is commonly done to prevent the bladder from protruding into the weakened vaginal wall (cystocele) or the rectum from protruding into the vagina (rectocele)

...

In this Repair category, the codes are often divided on the basis of the approach used

...

For example, an abdominal approach (open, 57270) to the repair of an enterocele (herniation of intestines through intact vaginal mucosa) has a different code than a vaginal approach (57268) to the same repair

...

and an anterior colporrhaphy (vaginal repair) (57240) differs from a posterior colporrhaphy (57250)

...

Pay particular attention to the approach used

...

You will find the approach documented in the operative report

...

One method of vaginal repair that is not in the Repair category is the laparoscopic repair

...

Codes for repair of the vagina using a colposcope (microscope) are located in the Vagina subheading, Endoscopy category

...

The colposcope enables the physician to directly view changes in the vagina and cervix

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Notes throughout the Repair category will frequently direct you to the correct code or code range in the Urinary System subsection

...

Often, the only difference between surgical procedures reported with Female Genital System codes and those reported with the Urinary System codes is the approach

...

For example, Female Genital System code 57330 describes the closure of a vesicovaginal fistula (abnormal channel between bladder and vagina) using a vaginal approach, whereas Urinary System code 51900 describes the same procedure using an abdominal approach

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The approach would be documented in the operative report

...

Manipulation

...

...

Manipulation of the vagina includes dilation (stretching), pelvic examination, and removal of foreign material

What these three different procedures have in common is that they are all performed under general anesthesia because a patient cannot tolerate the procedure while awake

...

If a local anesthetic or no anesthetic was used, which is the usual case, you would not use a Manipulation code (57400-57415)

...

instead, the service would be included in the Evaluation and Management (E/M) service

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For example, if a physician removed an impacted tampon from the vagina and used no anesthetic during the procedure, only the office visit at which the removal took place would be reported

...

Endoscopy

...

...

As discussed earlier in this chapter, the endoscopic procedure codes (57420-57426) in the Endoscopy category of the Vagina subheading are for colposcopic procedures

The colposcopic procedures are often bundled into other, more major procedures

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