Q Our physician performed colposcopy-directed vaginal biopsies and a transvaginal tape (TVT) procedure with cystoscopy. The diagnosis was a Pap result consistent with vaginal intraepithelial neoplasia I (VIN I). How should these procedures be coded?
A First, I hope there was another diagnosis besides VIN I—this condition justifies the directed biopsies but not the TVT procedure, which would be done for stress urinary incontinence (ICD-9-CM code 625.6).
For the TVT, the code you use will depend on the surgical approach. Use code 57288 for a vaginal approach or code 51992 for a laparoscopic approach. This sling procedure would be listed first on the claim, since it is the most extensive procedure.
Coding for the directed biopsies depends on whether your payer accepts the new CPT code for colposcopy with vaginal biopsy(s) (57421). If so, the claim should be submitted as 57288 or 51992 + 57421-51.
If your payer is still using the 2002 CPT codes, the only way to capture the colposcopy with vaginal biopsy would be to bill 2 codes: 57452 for the colposcopy plus either 57100 for a simple biopsy or 57105 for a biopsy that required suturing. Note that codes 57100 and 57452 are CPT “separate procedures” that are sometimes bundled together by the payer. For this reason, you’ll want to add modifier -59 (distinct procedure) to these codes. The result for these additional procedures: 57100-59-51 + 57452-59-51 or 57105-51 + 57452-59-51.
Some payers require modifier -51 (multiple procedure) be added when listing a second or third procedure, so their computer can handle the claim from a fee-reduction standpoint.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9CM coding. When in doubt on a coding or billing matter, check with your individual payer.