Decoding Coding: Office Hysteroscopy

The versatility of hysteroscopy allows for diagnosis and treatment of many problems, both in the office and in the operating theater. Properly coding and billing for these procedures and their indications is essential to be able to continue to perform them. The appropriate value should encourage appropriate use in the correct situation and discourage overuse or misuse. The procedures themselves are identified and described by the Correct Procedural Terminology (CPT) committee, managed by the American Medical Association (AMA). The resources required for these procedures are determined by the AMA/Specialty Society Relative Value Scale (RVS) Update committee (also known as RUC committee) which also suggests a value to the Centers for Medicare and Medicaid Services (CMS). However, the final determination of value is made by CMS.  By congressional mandate, the value of all CPT codes must be based on the time and the intensity of the procedure.

The Relative Value Unit (RVU) assigned to each procedure is the summation of expense for the physician work, practice expense, and malpractice insurance. The physician work is defined as the time, technical skill and effort, mental effort and judgement, and the stress involved in performing the service. The time is further divided into preservice time, intraservice time, and postservice time. The American College of Obstetricians and Gynecologists (ACOG) publishes annually the “Components of Correct Procedural Coding” manual which details all of the work included in each CPT code, the assigned RVUs, the surgical “global period”, and the current NCCI edits for Medicare and for other payers. This resource assists surgeons in knowing what is and isn’t included in each procedure and can be a valuable resource when appealing a claim.  Many times, the appeal only needs to include the appropriate documentation and a copy of the page detailing the CPT code from this manual to be paid.

The practice expense includes all the non-physician work (clinical and administrative) and the physical requirements for the practice, such as office space, office equipment and supplies, medical equipment and supplies, etc. Thus, when an office evaluation and management (E&M) code is billed on the same day as an office hysteroscopy procedure, the RVUs are discounted on the office visit as the patient only checks in once, uses one gown, uses one table, etc. When done on separate days, the full charge is applied to the E&M code and the procedure code because nothing is duplicated.

The practice liability portion is to cover the cost of malpractice insurance. Overall, this is less than 5% of the total RVU assigned. This is separate from the Geographic Adjustment of Medicare Payments to Physicians that factors the local cost of malpractice (and office rent and labor costs, etc.) into the final payment for service provided.

There are 8 codes for hysteroscopy (see Table 1). The base code in each family is usually included in any subsequent codes in the family. For example, when doing a 58558 (hysteroscopic polypectomy), the base code of the family, 58555 (diagnostic hysteroscopy) is included. The details on which codes can and cannot be reported together are published annually by CMS in the National Correct Coding Initiative edits (NCCI or CCI edits). Of note, regional anesthesia performed by the surgeon is not billable for CMS, thus a paracervical block (64435) is included in the work for many of these procedures.

Five of the hysteroscopy codes are valued differently when performed in an office rather than in a facility setting. The additional RVUs cover the practice expense that are not incurred by the provider’s office when done in a facility. For example, the hysteroscopic polypectomy code includes the cost of purchasing the scope, the fluid management system, the disposable devices used to resect the polyp, the disposable tubing, the fluids, the drapes, the gown, the gloves, the nursing time, the bed in the room, the light on the exam table, and so on. The work RVU is that part of the total RVU that is attributed to the actual work and time of the provider and includes consenting, examination on the day of the procedure, documentation of the procedure, and discussion with the patient and the family.

Each of these codes has a zero-day global period, which means that care provided on any other day is separately billable and care provided on the same day would require a modifier. For example, if the patient had an office visit on the same day (an evaluation and management code or E&M code), that would be billed with the -25 modifier. Payers, including Medicare, should cover both services, but sometimes an appeal is required.

Facility fees are a controversial topic. These are surcharges on outpatient services that a hospital is allowed to charge on top of the provider’s fees to cover practice expenses and are highly variable.  These fees can seem rather arbitrary and exorbitant. A simple internet search of “facility fees” on the internet will provide more than enough reading and background to satisfy curiosity. There are pros and cons to these fees as they are used to cover the more expensive overhead required by the joint commission for hospital-based offices. Most important in this era of transparency and patient autonomy, the practice should inform the patient if they will be charged a facility fee before providing the service.

Common Scenarios

1. A new patient presented for abnormal bleeding. I performed and exam and decided a hysteroscopy was medically necessary. I performed the diagnostic hysteroscopy on the same day. How do I code for this?

The correct code is a 58555 and a 9920x (new patient office visit where x is the appropriate level of service for what you provided, documented, and was necessary).  A -25 modifier should be attached to the E&M code. The ICD-10 code should reflect the final diagnosis (fibroid, polyp, AUB, etc.).

2. An established patient presented for IUD removal. No strings were present on exam. I used the hysteroscope to find the strings and remove the IUD, but the IUD was not impacted. How do I code for this?

There are two possible options. First, code a 58301 (Removal of IUD) with a -22 modifier to represent the additional work of the hysteroscope. It would be important to include the cost of the equipment that was separately used for the hysteroscope in the bill to the insurance company.  Second, code a 58555 much like one might perform and bill for an ultrasound to confirm the presence of the IUD if the practice did not have access to office hysteroscopy. If the IUD was impacted or embedded into the myometrium, the documentation must clearly state that it was indeed impacted and then the 58562 code would be appropriate. Because she was an established patient and she came in purely for the IUD removal, there is no E&M to be coded. It would not be appropriate to bill for an ultrasound that showed a normally placed IUD and a 58555 since the hysteroscopy was used solely to find the strings and not to see if the IUD was impacted.

Table 1