CPT Female Genital System | ALZONEOnlineTraining

CPT Female Genital System Guidelines

Surgery Female Genital System (56405-58999) codes are categorized as follows:

Vulva, Perineum, and Introitus* (56405-56821)

Incision (56405-56442)
Destruction (56501-56515)
Excision (56605-56740)
Repair (56800-56810)
Endoscopy (56820-56821)

Vagina (57000-57426)

Incision (57000-57023)
Destruction (57061-57065)
Excision (57100-57135)
Introduction (57150-57180)
Repair (57200-57335)
Manipulation (57400-57415)
Endoscopy/Laparoscopy (57420-57426)

Cervix Uteri (57452-57800)

Endoscopy (57452-57465)
Excision (57500-57558)
Repair (57700-57720)
Manipulation (57800)

Corpus Uteri (58100-58579)

Excision (58100-58294)
- Hysterectomy Procedures (58150-58294)
Introduction (58300-58356)
Repair (58400-58540)
Laparoscopy/Hysteroscopy* (58541-58579, 58674)

Oviduct/Ovary (58600-58770)

Incision (58600-58615)
Laparoscopy* (58660-58673, 58679)
Excision (58700-58720)
Repair (58740-58770)

Ovary (58800-58960)

Incision (58800-58825)
Excision (58900-58960)

In Vitro Fertilization (58970-58999)

Other Procedures (58999)

Maternity Care and Delivery* (59000-59899)

Antepartum and Fetal Invasive Services (59000- 59076)

Excision (59100-59160)

Introduction (59200)

Repair (59300-59350)

Vaginal Delivery, Antepartum and Postpartum Care (59400-59430)

Cesarean Delivery (59510-59525)

Delivery After Previous Cesarean Delivery* (59610-59622)

Abortion (59812-59857)

Other Procedures (59866-59899)

The Female Genital System subsection (56405-58999) is divided according to anatomic site, from the vulva up to the ovaries (see illustrations given above this content). The anatomic sites are then divided on the basis of category of procedure (i.e., incision, excision, destruction). Codes for in vitro fertilization are located at the end of the subsection. 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.

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 the Radiology Chapter.

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).

The following definitions apply to the vulvectomy codes (56620- 56640):

A simple procedure is the removal of skin and superficial subcutaneous tissues.

A radical procedure is the removal of skin and deep subcutaneous tissue.

A partial procedure is the removal of less than 80% of the vulvar area.

A complete procedure is the removal of greater than 80% of the vulvar area.

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 illustrations above).

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.

CAUTION NOTE: 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.

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.

E X T E N T

Simple skin and superficial subcutaneous tissue

Radical skin and deep subcutaneous tissue

S I Z E

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.

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.

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 (Refer illustrations below this content) 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.

The Vagina subheading includes the code range 57000-57426. Colpotomy (57000-57010) is cutting into the vagina to gain access to the pelvic cavity. The procedure is performed to explore the pelvic cavity or to drain a pelvic abscess. 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 the figure/image given below this content, tandem is a small, hollow metal tube that is inserted through the vagina into the uterus (intrauterine tandem). Vaginal ovoids are small metal cylinders that are placed into the vagina and positioned against the cervix (intravaginal ovoid). 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, see illustration/image below), diaphragm, or cervical cap (to prevent pregnancy); and packing of the vagina (for vaginal hemorrhage). Pessaries are used for vaginal prolapse. The pessary and diaphragm/ cervical cap are not included in these Introduction codes. The supply of these devices would be reported using code 99070, supplies, or a HCPCS code (e.g., 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. 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. 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. The approach would be documented in the operative report.

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. Only when a colposcopic procedure is performed as the only procedure or is unrelated to another procedure(s) being performed is the colposcopy reported. If a biopsy of the vagina or cervix is performed with colposcopy, the code to report the service is 57421. The code specifies “biopsy(s),” so whether one or multiple biopsies were taken, 57421 represents the total service.

The Cervix Uteri subheading contains codes (57452-57800) for endoscopy, excision, repair, and manipulation.

Endoscopy: Similar to the vaginal endoscopic codes, the colposcopy codes report procedures of the cervix uteri (57452-57461). A loop electrode excision procedure is referred to as LEEP, LETZ, or cervical loop diathermy and is an office procedure that uses heated wire (see illustration/image given below the content) to remove cervical tissue. The device is attached to an electric generator that heats the wire. The procedure has a lower risk level and is less expensive than other methods. A LEEP would usually be performed after an abnormal Pap smear result or an abnormal examination. The cervix is moistened, and the loop is positioned over the cervix and drawn across the area. The resulting slice is examined by a pathologist. The device is also used to cauterize the area at the end of the procedure by means of a different attachment.

Excision: The codes in the Excision category often specify “(separate procedure)” because many times the procedures are bundled into a more major procedure. For example, the excision procedure of a biopsy is often incidental to a more major surgical procedure, such as a hysterectomy, and the biopsy would not be reported separately.

Codes for conization of the cervix are divided on the basis of the method used to obtain the tissue (illustration/image given below this content). In conization, a cone of tissue is removed from the cervix for a biopsy or treatment of a lesion by means of excision of the lesion. Although a laser is a frequently used method of conization, LEEP technology is also widely used. The code for a LEEP procedure with cervical biopsy in the Cervix Uteri subheading, Endoscopy category, is 57460, and the code for a LEEP procedure with cervical conization is 57461. The difference between the codes is that the cervical biopsy procedure only removes a sample with return in the future if the lesion is to be completely removed. The conization procedure removes a cone-shaped tissue of the cervix after application of iodine to highlight the abnormal tissue. Also, the cervical biopsy is performed with the use of a colposcope (endoscopy), and the conization is performed using a speculum (illustration/image given below the content) (an instrument inserted into a cavity to stretch the opening). Be certain, when coding cervical biopsy and conization, that the information in the medical record provides sufficient detail to allow you to distinguish between a biopsy and a conization. If the record is not complete enough to make the determination, obtain the information from the physician before assigning a code.

Repair: Nonobstetric cerclage (repair of the cervix) involves extensive suturing of the cervix to decrease the size of the opening into the vagina (reported with 57700). Trachelorrhaphy (57720) is a complex cervical repair in which plastic methods are used to repair a laceration of the cervix. Both Repair codes use a vaginal approach.

Manipulation: Dilation of the cervix is coded separately only if it is the only procedure performed (57800). Dilation of the cervix, like dilation of the vagina, is usually bundled into a more major procedure.

The corpus uteri (58100-58579) is the anatomic area above the isthmus and below the opening for the fallopian tubes. The subheading contains the categories of excision, introduction, repair, and laparoscopy/hysteroscopy procedures. Many of the procedures in the category are very complex, and some of them have several variations. Let’s review some of the highlights of corpus uteri coding.

Excision: Endometrial sampling is a biopsy of the mucous lining of the uterus. The physician inserts a curet (spoon-shaped instrument) into the endocervical canal to extract tissue samples for pathologic examination. If the sampling is the only procedure performed, it is reported (58100, 58110), but if it is performed as part of a more major procedure involving the cervix, it is considered incidental to the more major procedure and is bundled into the surgical package.

Dilation and curettage (D&C; 58120) can be a diagnostic or therapeutic procedure performed when an endometrial biopsy has failed or was inconclusive or to determine the cause of abnormal bleeding or locate a neoplasm. Clamps are used to manipulate the cervix, a curet is inserted into the uterus, and fragments are removed from the endometrium. The tissue is sent to pathology for analysis. D&C in the Corpus Uteri subheading is for nonobstetric patients only. If a D&C is performed because of postpartum hemorrhage, a code from the subsection Maternity Care and Delivery would be assigned to report the service (59160).

Hysterectomy codes (58150-58294) represent the majority of the codes in the Corpus Uteri subheading. A hysterectomy is the removal of the uterus, but in the CPT manual there are many variations of this procedure. The division of the hysterectomy codes is based first on the approach (abdominal or vaginal), then on the secondary procedures (extent) that were performed (removal of tubes, biopsy, bladder, etc.). You have to read the code descriptions carefully to determine what is bundled into each code. Because so many procedures are bundled into some of the codes, you also have to be careful not to unbundle and code for items already covered in the main procedure.

For example, a total abdominal hysterectomy can include the removal of the ovaries and/or the fallopian tubes; therefore, billing separately for the removal of the ovaries or tubes would be unbundling. Within the Excision category there are codes for abdominal approaches for hysterectomies. An abdominal approach is one in which the surgeon opens the abdomen to view by means of an incision. Review the codes in the range 58150-58240 and underline “abdominal” in each of the codes as a reminder of the approach used in these codes. The other type of surgical approach for hysterectomies listed in the Excision category is the vaginal approach. Using the vaginal approach, the surgeon makes an incision in the vagina around the cervix and removes the uterus and/or ovaries/fallopian tubes (salpingo-oophorectomy) through the incision. The cuff of the vagina is then closed with sutures. Review the codes in the range 58260-58294 and underline “vaginal” as a reminder of the approach used in these codes.

Introduction: It is in the Introduction category (58300-58356) that you will locate the codes for some very common procedures such as the insertion and removal of an intrauterine device (IUD), as show in the image/illustration below this content, for birth control and for some not-so-common procedures such as artificial insemination. There are also several codes that have radiology components—your component coding skills will again be used. Because intrauterine device (IUD) insertion is reported using Introduction category code 58300, you might think IUD removal would be in a removal category, but it is in the Introduction category (58301).

Don’t confuse the insertion of an IUD with the placement of an implantable contraceptive such as Norplant, as described in the Integumentary subsection.

The specialized fertility procedure of artificial insemination (58321-58323) and the preparation of the sperm for insemination are reported with Introduction category codes. During the insemination procedure, sperm is injected into the cervix and often a cervical cap is inserted to keep the sperm in the cervical area. In vitro fertilization is a different procedure in which an egg from the female is withdrawn and fertilized with sperm in a laboratory for 2 to 3 days with subsequent implantation into the uterus. There is an In Vitro Fertilization subheading containing codes 58970-58976 to report these services, located at the end of the Female Genital System subsection.

Catheterization and introduction (58340) of saline or contrast material through the cervix and uterus and into the fallopian tubes (hysterosalpingography) is performed by a physician to identify blockage or abnormalities of the fallopian tubes. Ultrasound can also be used for the same procedure (hysterosonography). You need to remember your component coding and report the radiology or ultrasound portion of the procedure with a code from the Radiology section. A note following 58340 in the CPT manual directs you to the correct component code. For the radiographic supervision and interpretation, the component code is 74740; for the ultrasound (sonohysterography), the code is 76831.

A hysterosalpingography is a diagnostic procedure to test the patency (unblocked) of the fallopian tubes. Saline or contrast material is injected into a tube (58340). A catheter may be introduced (58345) and passed through the fallopian tube using x-ray to show where the catheter encounters an obstruction or a narrowing of the tube. A code from the Radiology section, Gynecological and Obstetrical subsection, would report the radiology portion of the service (74742). Chromotubation (58350) is a surgical procedure to open an obstructed or narrowed tube.

Laparoscopy/Hysteroscopy: An increasing number of procedures are being performed by using an endoscope instead of opening the area to complete view. With an endoscopic procedure, usually two or three small incisions are made through which lights, cameras, and instruments may be passed. The surgeon first inserts an instrument into the vagina to grasp the cervix. The laparoscope is then inserted into the abdomen and the uterus and/or ovaries/fallopian tubes are excised. An incision is made in the vagina and the surgically excised material is removed through the vaginal incision. The vagina is then repaired by means of sutures. Review the codes in the range 58541-58579 and underline “Laparoscopy” or “Hysteroscopy” as a reminder of the approach used in these codes. It is very important to read the full code description to identify the approach. Because endoscopic procedures are less invasive, patients are more accepting of the procedures, and recovery times and risks are reduced. Image/illustration given above this content, a laparoscopy procedure and a laparoscopy/ hysteroscopy procedure.

The first rule of a laparoscopy or hysteroscopy is that all surgical procedures include a diagnostic procedure. You never unbundle a surgical laparoscopic procedure by also reporting a diagnostic procedure. If a procedure started out as a diagnostic laparoscopic procedure and ended up being a surgical laparoscopic procedure, you report only for the surgical laparoscopy. The codes in the Laparoscopy/Hysteroscopy category are divided on the basis of approach— laparoscopy or hysteroscopy—and further divided by other procedures that might have been performed.

CAUTION: f the laparoscopy is of the peritoneum, you assign a code (49320) from the laparoscopy category of the Digestive System, Abdomen, Peritoneum, and Omentum subheading.

Oviduct/Ovary: The Oviduct/Ovary subheading (58600-58770) is divided into incision, laparoscopy, excision, and repair. Fallopian tube procedures are located in this subheading.

Incision: The Incision category is where you will locate the codes for tubal ligation, which is a permanent, highly effective method of birth control. The codes are divided according to the type of ligation performed and the circumstances at the time of the ligation. The types of ligation are as follows: tying off the tube with suture material (ligation), removing a portion of the tube (transection), and blocking the tube with a device, such as a clip, ring, or band (occlusion). The circumstance under which the procedure is performed affects the choice of codes. For example, a procedure can be performed either on one side (unilateral) or on both sides (bilateral). The procedure can be performed at different times, such as during the same hospitalization period as the period of delivery, during the postpartum period, or during another surgical procedure and these circumstances affect code assignment.

Do not use a bilateral procedure modifier (-50) with codes in the Incision category because the code descriptions indicate “tube(s)” or “unilateral or bilateral.” Also, do not code tubal ligations performed by means of a laparoscopic procedure using the Incision category codes. There are codes for laparoscopic tubal ligation procedures in the Laparoscopy category of subheading Oviduct/Ovary (58660-58679).

A ligation can be performed by an abdominal or a vaginal approach. If a ligation or transection of the fallopian tube(s) is performed during the same operative procedure as a cesarean delivery or other intra-abdominal surgery, you report the ligation/transection using 58611. Code 58611 only reports the tubal ligation as a component of the more major surgical procedure and is listed in addition to the primary code. Often at the time of an abdominal tubal ligation, lysis (loosening) of adhesions will be performed. Lysis is not bundled into the ligation code. You report the lysis of adhesions separately, using a Repair category code such as 58660, if allowed by the third-party payer.

58740, lysis of adhesions, is performed for restoration of fertility, not for lysis of adhesions at the time of tubal ligation (such as 58660).

Laparoscopy: The procedures described in the Oviduct/Ovary subheading, Laparoscopy category (58660-58679) are surgical laparoscopy and always include a diagnostic laparoscopy. If only a diagnostic laparoscopy was performed, you report 49320 from the Digestive System subsection, Abdomen, Peritoneum, and Omentum category, because the scope is being passed into the abdomen for examination only. Once a definitive procedure such as a tubal ligation has begun, the examination/diagnostic laparoscopic procedure is bundled into the surgical procedure.

For example, if a diagnostic laparoscopy was performed and did not lead to a definitive procedure, the diagnostic laparoscopic code 49320 from the Digestive System subsection would be reported to describe the procedure of examining the abdomen using an endoscope. But if a diagnostic laparoscopy was performed and did lead to a fulguration of the oviducts, code 58670 from the Female Genital System subsection would be assigned. The terminal (end or final) procedure dictates the code choice. The laparoscopy codes are divided on the basis of the procedure performed, for example, lysis of adhesions, oophorectomy, and lesion excision.

Excision: The Excision category codes report salpingectomy (removal of uterine tube) or salpingo-oophorectomy (removal of uterine tube and ovary) and describe unilateral or bilateral procedures that are either complete or partial. An unbundling issue presents itself with the assignment of these codes. If either a salpingectomy or salpingo-oophorectomy is performed with a more major procedure such as a hysterectomy, each is considered bundled into the more major procedure and not reported separately.

Repair: Within the Repair category are codes for lysis of adhesions and various repairs to the fallopian tubes. All of the repairs are performed for the purpose of restoring fertility. Often the repairs are made through small incisions above the pubic hairline, but they can also be performed through a laparoscope, so note the approach used for repairs to the fallopian tubes. Lysis of adhesions performed on the fallopian tubes (salpingolysis) or the ovaries (ovariolysis) uses a small incision to insert instrumentation to complete the repairs. Lysis is a procedure that is often performed at the time of another, more major procedure and is usually bundled into the more major procedure. If the lysis takes an extensive amount of time, you can report the service separately with supportive documentation indicating the additional time and effort required to perform the lysis. Another option is to report modifier -22 to indicate that the procedure required more time than normal. The time to complete the lysis portion of the procedure must be clearly documented in the operative report.

The subheading Ovary (58800-58960) contains the two categories Incision and Excision. The Incision codes report ovarian incision and drainage. The Excision codes report ovarian biopsy, cystectomy, and oophorectomy procedures

Vitro Fertilization : In vitro fertilization means to fertilize an egg outside the body. The codes in the In Vitro Fertilization category describe several methods that are used in modern fertility practice. Third-party payers often do not pay for the fertility treatments. You will have to be certain that you know the policy of the payer regarding fertility treatments. Code 58970, aspiration of the ova, is often performed with ultrasonic guidance and when it is, assign 76948 (Radiology section, Ultrasonic Guidance Procedures) to report the service.

MATERNITY CARE AND DELIVERY:

Format:

The Maternity Care and Delivery subsection (59000-59899) is divided according to type of procedure. As a general rule, the subsection progresses from antepartum procedures through delivery procedures. The guidelines are very detailed as to the services included in antepartum and delivery care, not only to facilitate coding but also to help guard against unbundling.

Notes at the beginning of this subsection describe, in depth, the services listed in obstetric care. Be certain to read these notes. Abortion codes, whether for spontaneous abortion, missed abortion, or induction of abortion, are at the end of the subsection.

Abortion codes indicate treatment of a spontaneous abortion or missed abortion, including additional division on the basis of trimester and induction of abortion by method. You must be aware of the gestational age of the fetus to determine the correct code. Treatment for ectopic pregnancies is based on the site of the pregnancy, the extent of the surgery, and whether the approach was by means of laparoscopy or laparotomy (incision through abdominal wall).

Maternity and Delivery The gestation of a fetus takes approximately 266 days; but when the estimated date of delivery (EDD) is calculated, 280 days are often used, counting the time from the last menstrual period (LMP). The gestation is divided into three time periods, called trimesters. The trimesters are as follows:

First LMP to week 12

Second Weeks 13-27

Third Weeks 28-EDD

When a maternity case is uncomplicated, the service codes normally include the antepartum care, delivery, and postpartum care in the global package. Antepartum care is considered to include both the initial and subsequent history and physical examinations, blood pressures, patient’s weight, routine urinalysis, fetal heart tones, and monthly visits to 28 weeks of gestation, biweekly visits from gestation weeks 29 through 36, and weekly visits from week 37 to delivery when these services are provided by the same physician. If the patient is seen by the same physician for a service other than those identified as part of antepartum care, you would report that service separately

For example, if a patient in week 32 came to the office with a chief complaint of cold symptoms, an E/M service code would be reported for the service and the diagnosis code would further indicate that the service was provided due to a cold not pregnancy. Admission to the hospital is bundled into the delivery codes and includes the admitting history and examination, management of an uncomplicated labor, and delivery that is either vaginal or by cesarean section (including any episiotomy, illustration/image shown below content shows use of forceps, Included in postpartum care are the hospital visits and/ or office visits for 6 weeks after a delivery. If the postpartum care is complicated or if services provided to the patient during the postpartum period are not generally part of the postpartum care, you would report those additional services separately.

Routine Obstetric Care:

There are four codes that describe the global routine obstetric care that includes the antepartum care, delivery, and postpartum care, based on the type of delivery:

59400 Vaginal delivery

59510 Cesarean delivery

59610 Vaginal delivery after a previous cesarean delivery

59618 Cesarean delivery following attempted vaginal delivery after previous cesarean delivery.

Two abbreviations commonly found on the delivery record are VBAC (vaginal birth after cesarean) and VBACS (vaginal birth after cesarean section), which assist in assigning the correct code.

Bundled into the vaginal deliverycodes are an episiotomy(cutting of the perineum) and/or the use of forceps during delivery and, therefore, neither is reported separately.

If the physician provided only a portion of the global routine obstetric care, the service is reported with codes that describe that portion of the service as delivery only or postpartum care only, based on the delivery method.

For example, if a physician provided only the delivery portion of the service, you would report the service with:

59409 Vaginal delivery only

59514 Cesarean delivery only

59612 Vaginal delivery only, after previous cesarean delivery

59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery.

If the global obstetric care is provided and twins are delivered, the same codes are reported but, depending on the third-party payer, modifier -22 (Increased Procedural Services) or -51 (Multiple Procedures) is added.

Usually, if both twins are delivered vaginally, report 59400 for Twin A and 59409-51 for Twin B. If one is delivered vaginally and one is delivered cesarean, report 59510 for Twin B and 59409-51 for Twin A. If both are delivered via cesarean, report only 59510 (because only one cesarean was performed).

Antepartum Services : Amniocentesis (59000, 59001) is a procedure in which the physician inserts a needle into the pregnant uterus to withdraw amniotic fluid and is only performed after the first 14 weeks of pregnancy. In this procedure, ultrasound is used to guide the needle, and the supervision and interpretation (S&I) service is reported using 76946 from the Radiology section, Ultrasonic Guidance Procedures subsection.

Radiological procedures require a separate medical document before you can submit for reimbursement. Modifier -26 may be required depending on where the service was performed and who owned the radiology equipment

Several of the antepartum services require component coding in order to fully report the services provided. Attention to the code descriptions and parenthetic statements is necessary to ensure that all services are reported.

Cordocentesis (59012) is a procedure in which fetal blood is drawn. This procedure is performed under ultrasonic guidance to assess the status of the fetus. Cordocentesis is not included in normal antepartum care and should be reported separately. The ultrasonic guidance (76941) would also be reported separately.

Excision: Abdominal hysterotomy (59100) may be performed to remove a hydatidiform mole (cyst like structure) (see illustration/image above this content) or an embryo. If a tubal ligation is performed at the same time as a hysterotomy, be certain to report 58611 to indicate the ligation.

An ectopic pregnancy is one in which the fertilized ovum has become implanted outside of the uterus, as illustrated in the image above this content. The surgical treatment for this condition can use either an abdominal or a vaginal approach (59120-59150); most often, the abdominal approach is used. If the area has not ruptured, the pregnancy is removed. If a rupture has occurred, a more extensive procedure is required. You have to identify the location of the ectopic pregnancy, the extent of the necessary repair, and the approach to the repair—vaginal, abdominal, or laparoscopic—to correctly code the procedure.

Postpartum curettage is performed within the first 6 weeks after delivery to remove remaining pieces of the placenta or clotted blood. Code 59160 is only for use with postpartum curettage. If the curettage is nonobstetric, report 58120.

Introduction. A cervical dilator (such as laminaria, which is a compound on a stick that swells from surrounding moisture) may be inserted prior to a procedure in which the cervix is to be dilated; it prepares the cervix for an abortive procedure or a delivery. The dilator initiates uterine contractions, which in turn cause cervical dilatation. Induction can be elective—at the convenience of the patient or the physician—or required, based on a medical risk factor to the mother or fetus. Physicians use a scoring system to measure the stage of cervical ripening, as illustrated in the image below this content.

To induce cervical ripening (softening and dilation), a preparation such as Prepidil gel is introduced intracervically using a catheter. The cervical ripening takes place in the delivery ward.

You can report 59200 (cervical ripening) with an induced abortion (59840 or 59841) but not with an abortion induced by means of vaginal suppositories (59855-59857). Also, do not report an induction procedure using a code that describes a manual dilation as a part of the procedure, such as D&C.

Repair: The obstetric repairs can be to the vulva, vagina, cervix, or uterus. All of these repairs are also located in the Female Genital subsection, but here in the Maternity Care and Delivery subsection, the codes are reported only for repairs made during pregnancy. Repairs made during delivery or after pregnancy are included in the delivery codes 59400-59622.

Vaginal repairs can be reported separately only by a physician other than the attending physician. When the attending physician performs a procedure such as an episiotomy, it is considered part of the package for obstetric care. Each third-party payer determines what is included in the obstetric package.

Abortion Services: The abortion codes (59812-59857) include services for treatment for several types of procedures. A spontaneous abortion (miscarriage) is one that happens naturally. If the uterus is completely emptied during the miscarriage and the physician manages the postmiscarriage, the services are reported with E/M codes. Sometimes the abortion is incomplete and requires intervention to remove the remaining fetal material (59812). A missed abortion is one in which the fetus has died naturally sometime during the first half of the pregnancy but remains in the uterus. The physician removes the fetal material from the uterus and reports the service based on the trimester in which the service was provided (59820-59821). A septic abortion, whether induced or missed, has the added complication of infection. The physician removes the fetal material from the uterus and vigorously treats the infection (59830).

The induced abortions are those in which the death of the fetus is brought about by medical intervention (59840-59857). One of three methods is used: dilation with either curettage (scraping) or evacuation (removal by means of suction), intra-amniotic injections, or vaginal suppositories. The selection of the code depends on which of the three methods was used to accomplish the abortion. Dilation and curettage is a procedure in which the cervix is dilated and the fetal material is scraped out by means of a curet. When the dilation and evacuation method is used, the cervix is dilated and the contents are suctioned out by means of a vacuum aspirator. The intra-amniotic injections are of urea or saline, which induces an abortion. Vaginal suppositories (such as prostaglandin) can be inserted into the cervix, with or without cervical dilation, to induce an abortion. A hysterotomy (cutting into the uterus, 59857) may be performed if the medical intervention by injection or vaginal suppositories fails.

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