Colporrhaphy? Do not code for posterior repair
Q We have been told that we can report code 45560 (repair of rectocele [separate procedure]) for posterior repair of a rectocele. I’ve noted that the relative value units (RVUs) for this procedure are higher than for a posterior colporrhaphy. Please clarify: When is it appropriate to bill 45560?
A The simple answer is that you must bill the procedure that you’ve documented, and colporrhaphy is the procedure performed by 99% of ObGyns to repair a rectocele. Typically, this involves making a midline incision in the posterior vaginal wall, plicating rectovaginal tissue, suturing it together, cutting off excess tissue, and, sometimes, supporting weakened rectovaginal tissue with mesh.
The code 45560, on the other hand, is listed in the digestive section of CPT and is, basically, a transanal approach procedure that has a vaginal component. It is much different than posterior colporrhaphy, and is typically performed when a patient with a rectocele has fecal incontinence.
Although 45560 does carry slightly more RVUs than 57250 (posterior colporrhaphy, repair of rectocele with or without perineorrhaphy), the physician work portion of the RVU total for both codes is now identical: 11.42.
Last, be aware: Payers consider it fraud for a surgeon to use the wrong code in this situation because it pays more, when, in fact, colporrhaphy has been performed and documented.
Patient asks for test; is that “medical necessity”?
Q Occasionally, we see a patient with a family history of ovarian cancer who requests a test for cancer antigen 125. If the result is elevated and we decide to perform a US scan, what diagnosis code should we add for medical necessity? Our experience using a family history code with payers has not been good.
A The correct primary diagnosis code for this situation is 795.82 (elevated cancer antigen 125), followed by V16.41 (family history of malignant neoplasm; genital organs; ovary).