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Reimbursement Advisor

A new year, a new CPT: Will these changes rattle your practice?

You need to revise your encounter form; Modifier -21 is gone; and there’s mixed news about common urogyn surgeries. Our expert contributor offers a walk-through.

January 2009 · Vol. 21, No. 01


New bivalent HPV vaccine, new code

“Modifier -21” for extended E/M services is eliminated

RVUs fall for slings, sling revisions—how much of a drop?

This week's quiz:
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The author reports no financial relationships relevant to this article.

Take note, ObGyns: A number of changes in Current Procedural Terminology (CPT) 2009—those changes took effect January 1—are going to modify the way you bill and will have an impact on your reimbursement. Most of these changes are minor, although renumbering of infusion codes will require changes to the encounter form. And I have good and bad news for urogynecologists who perform vaginal paravaginal repairs and sling procedures for stress urinary incontinence. Read on for details!

Mesh for vaginal paravaginal defect repair—
code error corrected

Code 57267 is an add-on code that describes the insertion of mesh, or other prosthesis, through a vaginal approach when native tissues have been determined to be weak and inadequate for repair—especially in patients who have undergone a previous attempt at repair. As an add-on code, it can be billed only in addition to other, specific procedures.

Before January 1, code 57267 could only be reported with an anterior or posterior colporrhaphy, or both, or with a rectocele repair without colporrhaphy.

When performing a vaginal approach paravaginal defect repair, however, the same weakened tissues also require use of the mesh, yet code 57825 (paravaginal defect repair [including repair of cystocele, if performed]) was not included as one of the allowed codes. This error is rectified in 2009.

You must still be aware that reporting the 57267 add-on code requires that you establish medical necessity for its use. Documentation of weakened, attenuated, or incompetent pubocervical tissue in the case of a paravaginal repair (International Classification of Diseases Clinical Modification [ICD-9-CM] code 618.81) or rectovaginal tissue for rectocele/enterocele repair (618.82) continues to be important when reporting the add-on mesh code.

NOTE: Any mesh used with a colpopexy, sling procedure, or abdominal or laparoscopic paravaginal repair is not reported separately.

A reminder about anesthesia

Until January 1, codes 57400 (dilation of vagina), 57410 (pelvic examination), and 57415 (removal of impacted vaginal foreign body) read “under anesthesia.” In a move to standardize terminology, these codes will be revised to add the wording “other than local.” The revision clarifies that 1) all surgical codes include administration of a local anesthetic and 2) codes designated with “under anesthesia” refer to regional blocks and general anesthesia.

Down with the work relative value
of 2 urogynecology procedures for UI!

Although not a CPT change, it’s worth noting that physicians who perform 1) sling operations for correcting stress urinary incontinence or 2) subsequent revisions because of problems with fascia or synthetic mesh need to be aware that the physician work relative value for these procedures has been decreased in 2009 by the Centers for Medicare and Medicaid Services (CMS). Why the drop? According to CMS, results of surveys by the American Urogynecologic Society and the American Urological Association indicate that the procedures are not as difficult to perform as once considered.

The two affected codes are:


Sling operation for stress incontinence (e.g., fascia or synthetic)


Removal or revision of sling for stress urinary incontinence (e.g., fascia or synthetic)

The change will result in a decline in payment for these procedures by Medicare and some non-Medicare payers, and will be felt harder with sling procedures than with revisions. Why? The work relative value units (RVUs) decreased for 57287, but that decrease was offset by an increase in practice expense relative value—which resulted in total RVUs increasing for this code in 2009, from 18.31 to 18.53.

Code 57288, on the other hand, has been tagged with a decrease in both the physician work and practice expense RVUs. Total RVUs for this code, therefore, have dropped from 21.59 to 19.62. In Medicare dollars, that equates to about $118 less for the same procedure when one applies the 2009 Medicare conversion factor of $36.07.

New human papillomavirus vaccine, new code

A new code, 90650, has been added to report the newer bivalent human papillomavirus (HPV) vaccine, which contains an adjuvant formulation and is intended to protect against infection by high-risk HPV types 16 and 18. The existing HPV vaccine code, 90649, targets those high-risk types of HPV and two low-risk types (6 and 11).

Coverage recommendations for the new vaccine match those of the existing, quadrivalent vaccine, but not all payers are covering the HPV vaccine based on those recommendations. The new vaccine offers a less costly alternative for patients whose health-care insurance does not cover the vaccine or who are uninsured.

NOTE: The dosing schedules for these HPV vaccines also differ: the new vaccine: administered at 0,1, and 6 months and the existing vaccine: administered at 0, 2, and 6 months.

Wholesale reorganization of injection and infusion codes

Codes 90760–90779 (covering therapeutic, prophylactic, and diagnostic injections and infusions) are deleted in 2009 and renumbered, with the same descriptors, to 96360–96379. This was done to organize all infusions and injections together. The biggest change for you and every other ObGyn? You must revise the practice’s encounter form to reflect the requirement that intramuscular and subcutaneous injections are now coded 96372 instead of 90772.

Modifier -21 and prolonged E/M services

Now deleted is Modifier -21 (prolonged evaluation and management [E/M] service). This modifier represented acknowledgment that a continuous face-to-face E/M service could exceed the maximum time allowed by the highest level of E/M service for the type being billed.

In other words, before January 1, 2009, if a patient’s condition was such that you documented an established or new patient visit (99215 or 99205) but in fact spent more time with her than the 45 or 60 minutes that typically accompanies these codes, you added modifier -21 in the hope of receiving higher reimbursement. Now the modifier is deleted because there is already a mechanism in place to report such prolonged service.

Add-on codes 99354–99357 are used to report face-to-face outpatient and inpatient prolonged E/M services. Guidelines for these codes mandate cumulative time rather than continuous time, and using the add-on codes is contingent on the additional time spent being 30 or more minutes above the typical time allotted for the basic E/M service that you are billing.

Here’s a case that exemplifies how coding works in these circumstances:


You evaluate a patient for severe uterine bleeding, and report a level-4 visit (99214), which has a typical time of 25 minutes. At the same visit, you determine that endometrial biopsy is required, and you perform it during the visit. But the patient faints during the procedure—and you spend an additional 35 minutes (cumulative time) with her before you send her home.

Because the typical time of 25 minutes was exceeded by at least 30 minutes, you should report 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [list separately in addition to code for office or other outpatient Evaluation and Management service]) in addition to 99214.

Guidelines for correct use of these codes are also being revised to emphasize that only outpatient prolonged services codes are intended to be used to report total duration of face-to-face time; on the other hand, inpatient codes are intended to report the total duration of the time spent (whether continuous or noncontinuous) by the physician on the unit actively involved in caring for the patient.

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