Avoid confusion over terms when billing McCall culdoplasty ... Complete and transvaginal US scan must be specified
Avoid confusion over terms when billing McCall culdoplasty
<huc>Q</huc> I performed a McCall culdoplasty following vaginal hysterectomy, but the insurance company denied payment for the culdoplasty, stating that this procedure is included in the hysterectomy. How do I appeal?
<huc>A</huc>Denial could take place only if the incorrect code combination was billed. For example, if your billing staff itemized the procedures by reporting 58260 for the vaginal hysterectomy and 57268 [Repair of enterocele, vaginal approach (separate procedure)], then the enterocele repair (McCall) would be denied as inclusive, as these two codes are bundled. But they are bundled because there are 4 codes that combine enterocele repair with vaginal hysterectomy, depending on the documented weight of the uterus and whether you took, or left, the tubes and ovaries.
Your code choices are:
58263 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele
58270 Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele
58292 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele
58294 Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele
Don’t blame your billing staff if this is what occurred. The term “McCall culdoplasty” appears nowhere in the CPT book, so your billers would need to know that you actually performed an enterocele repair.
Correctly communicating what you did is an important step in getting the claim paid in a timely manner. Refile with the correct code!
Read a description of the technique of McCall culdoplasty.
Complete and transvaginal US scan must be specified
<huc>Q</huc> Regarding ultrasonography (US) codes 76856 and 76857, are these codes for an abdominal or a vaginal approach? Recently, we scanned a patient transvaginally for a complete US study (uterine, ovary, stripe, etc) but could not determine which code to use. My understanding has been that code 76830 is for a limited transvaginal scan.
<huc>A</huc>Codes 76856 [Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation; complete] and 76857 [Ultrasound…; limited or follow-up (eg, for follicles)] describe a transabdominal approach. If you performed a complete transvaginal scan, the code would be 76830, which is not a limited scan. In fact, the physician work relative value units assigned to these codes are identical, at .69. The only code for a limited gynecologic US would be 76857. If you performed a limited US by a vaginal approach, however, you can bill 76830 with a modifier -52 (reduced services) added to indicate that you did not perform a complete scan.