Hot Coding Topics

Myomectomy Claims: Anatomical Location Is Your Key

Deciding which myomectomy code you’ll report depends on three factors: the approach the ob-gyn uses, the number of myomas, and their weight. Here’s how to translate this information into the correct CPT code every time.

If your ob-gyn performs a hysterectomy, you won’t report the myomectomy separately.

When your ob-gyn performs a myomectomy, he is removing myomas or uterine fibroid tumors. Knowing what type they are will help you to determine your myomectomy code.

Myomas (also known as uterine fibromas) are the most common growth of the female genital tract. They are round, firm, benign masses of the muscular wall of the uterus and are composed of smooth muscle and connective tissue. You’ll see different types of uterine fibroids based on their location:

  • Intracavitary myomas are fibroids inside the uterus.
  • Submucous myomas are partially in the uterine cavity and partially in the wall of the uterus.
  • Subserous myomas are on the outside wall of the uterus.
  • Intramural myomas are in the wall of the uterus; their size can range from microscopic to larger than a grapefruit. These take a lot more effort to remove than a surface myoma.
  • Pedunculated myomas are connected to the uterus by a stalk and are located inside the uterine cavity or on the outside surface.

Myomas often cause or are coincidental with abnormal uterine bleeding, pressure or pain. They are also one of the most common reasons women in their 30s or 40s have hysterectomies, says Peggy Stilley, CPC, COBGC, ACS-OB, director of auditing services at the American Academy of Professional Coders.

However, women who want to have children in the future or simply do not want their uterus removed look for alternative solutions. The following procedures describe abdominal, vaginal, and laparoscopic approaches.

First of all, look at the abdominal approach. When...

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February 5, 2011
Hot Coding Topics

Therapy Progression Is Your Key to Correct Whiplash Coding

Be on a look out for Scans, TPIs, and more

Though coding for whiplash diagnosis and treatment is pretty straightforward, you should still watch out situations when the patient’s symptoms persist despite conservative therapy and warrant more extensive treatment. You will miss your pay if you miss these diagnoses.

When a patient presents with whiplash symptoms, your pain management specialist will conduct a thorough exam and will often order neck x-rays to rule out fractures. On diagnoses of whiplash (847.0, Sprains and strains of other and unspecified parts of back; neck sprain), he typically will prescribe conservative treatment. Common options include physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants. Some patients may also benefit from wearing a soft cervical collar or by using a portable traction device.

If conservative treatment fails, the physician might order additional diagnostic imaging tests. These could include:

  • CT scans – 70490 (Computed tomography, soft tissue neck; without contrast material), 70491 (… with contrast material[s]) and 70492 (… without contrast material followed by contrast material[s] and further sections)
  • MRIs – 70540 (Magnetic resonance [e.g., proton] imaging, orbit, face and/or neck; without contrast material[s]), 70542 (… with contrast material[s]) and 70543 (… without contrast material[s], followed by contrast material[s] and further sequences)
  • Bone scans – CT, MRI, and x-ray tests include basic bone scans. If your physician orders more extensive bone scans for the patient, you might to get authorization for 78300 (Bone and/or joint imaging; limited area) or 78305 (… multiple areas) instead.

Correctly Count Trigger Point Injections

Your physician might also administer trigger point injections to relieve the patient’s pain and muscle tenderness. Code these procedures with 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) or 20553 (…three or more muscles).

Because of the “one or two muscles” and “three or...

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February 5, 2011