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On October 1, 2014, the Centers for Medicare and Medicaid Services (CMS) and the National Correct Coding Initiative (NCCI) implemented a number of new coding pair edits that significantly restricted the types of surgical procedures that could be billed at the same time as vaginal hysterectomy. Most importantly, the new edits did not allow for combined anterior and posterior (AP) vaginal repair (57260) and apical vaginal suspensions (57282, 57283) to be separately billed and reimbursed when performed by the same surgeon and done in the same surgical session as a vaginal or laparoscopic hysterectomy. I initially reported on these changes in the January 2015 issue of OBG Management (“Recent NCCI edits have significantly impacted billing and reimbursement for vaginal hysterectomy”).
AUGS, ACOG, and others responded, and were heard
As a result of an intensive effort, the American Urogynecologic Society (AUGS), in conjunction with the American College of Obstetricians and Gynecologists (ACOG), the Society of Gynecologic Surgeons (SGS), and other professional societies, NCCI has agreed to change or modify a significant number of these pair edits.
As described in my earlier article, NCCI periodically reviews multiple surgical procedures performed in the same setting by a single surgeon to determine whether there is a significant overlap in services and therefore, in their opinion, redundant payment. Most significantly, CMS agreed with the argument made by the AUGS task force that it was inappropriate to bundle combined colporrhaphy with the various vaginal hysterectomy codes. These pair edits will no longer exist, and it is possible to bill separately for an AP repair performed in the same session as a vaginal hysterectomy—and expect additional payment for this procedure (subject to the multiple procedure reduction modifier -51).
Don’t miss out on reimbursement for your prior surgeries
It is important to recognize that this decision will be retroactive to October 1, 2014, which means that surgeons can resubmit charges for procedures performed between October 1, 2014, and March 31, 2015.
An exception to this rule is when the surgeon performs, and bills for, a vaginal hysterectomy code that includes enterocele repair, such as 58263. In these circumstances, the combined colporrhaphy remains bundled with the vaginal hysterectomy, unless a special modifier is used.
When can a modifier be used?
With regard to the majority of the other pair edits, CMS still contends that the edits are appropriate; however, they have modified the edits to allow for these procedures to be billed separately when the surgeon feels that substantial additional work has been performed. For example, CMS holds the position that all vaginal hysterectomies include some type of apical fixation to the surrounding tissues—such as fixation of the vaginal cuff at the time of closure to the distal uterosacral ligaments. However, it will allow for the additional billing for a more extensive vaginal apical suspension (such as a high uterosacral suspension or sacrospinous ligament suspension) as long as the surgeon documents the additional work performed and submits the claim using one of the NCCI-approved surgical modifiers. In this particular circumstance, the -59 modifier is the appropriate choice.
The AUGS task force also had objected to the bundling of a group of codes that, in the society’s opinion, were distinctly unrelated, such as a laparoscopic hysterectomy or vaginal hysterectomy combined with a sacral colpopexy performed through an open abdominal incision. CMS recognizes that these codes are used infrequently together and has therefore assumed that they may be billed in error. AUGS, however, has pointed out that, on occasion, a laparoscopic hysterectomy with an intended laparoscopic colpopexy may be converted to an open procedure due to a complication or technical difficulty, in which case the use of both codes would be appropriate.
The NCCI response was to keep the code pairs bundled but allow for billing with the -59 modifier.
We have cause for cheer, but bundling edits continue
Overall, these changes in pair edits represent a significant improvement in reimbursement for gynecologic surgeons, relative to the changes that went into effect on October 1. A more detailed explanation and list of the codes affected can be found on the AUGS Web site (http://www.augs.org). I emphasize again that these changes not only are in effect as of April 1, 2015, but also are retroactive to October 1, 2014.
Unfortunately, while AUGS and ACOG were advocating for these changes on behalf of gynecologists, NCCI recently has approved 6 additional pair edits that will go into effect on July 1. These changes specifically involve related procedures done at the time of vaginal hysterectomy with enterocele repair (58263, 58270 and 58294, 58292) and posterior vaginal repair (57250).
