Ob-Gyn ICD-9, CPT, HCPCS Coding - ABCs of Biopsies A Diagnostic Coding Primer

Coding for gynecological biopsies when performed as stand-alone procedures or in conjunction with other services constitutes significant revenue for many ob/gyn practices. Frequently, biopsies are done because of suspected malignancies but come back negative. This is good news for the patient but presents a coding problem when it comes to showing medical necessity. An understanding of the different types of biopsies, documentation requirements, and which ICD-9 codes need to be linked for proper reimbursement means fewer billing errors and more accurate reimbursement.

Reporting a justifying ICD-9 code is more important than ever before, says Melanie Witt, RN, CPC, MA, an independent coding educator and ob/gyn coding expert, because payers consistently look for close diagnostic matches before paying for expensive procedures. \The payer is looking for a match between the procedure and reason for doing it, and it is the payer who decides whether the code used justifies the procedure per their coverage policy,” she says. In addition, due to the many possible diagnoses and their often slight variations from one another, coders must be particularly diligent in choosing the right ICD-9 code.

Simply put, a biopsy is a tissue sample that is excised from the patient to ascertain the presence of cancer. In the gynecological setting, physicians are most likely to perform biopsies of the vulva, cervix, vagina, endometrium and ovary(s). Biopsies can be ordered as a result of abnormal vaginal bleeding or after the detection of a mass, cyst, lump, tumor or cells of abnormal appearance.

Endometrial Biopsy This procedure extracts samples from the tissue lining (endometrium) the inside of the uterus. A plastic catheter is inserted into the uterus, and a small amount of the endometrial lining is suctioned out. The procedure is done vaginally either alone or in conjunction with other gynecological surgery. The procedure can be ordered as a result of several diagnoses. The most common reasons for performing an endometrial biopsy are abnormal uterine bleeding (626.6, 626.9), amenorrhea (626.0), and menopausal and postmenopausal disorders (627.0, 627.1, 627.9). Secondary diagnoses, or those recorded in the absence of other symptoms, are history or family history of cancer (V10.41, V10.42, V10.44, V16.49) and estrogen therapy (V07.4).

CPT has two codes for endometrial biopsy: 58100* (Endometrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, any method [separate procedure]) and 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D & C). Code 58100 defines a fairly straightforward procedure that can be done in the office, without general or local anesthesia in most cases. As a starred code, the procedure includes no pre- or postoperative care or global period. Code 58100 can be billed in conjunction with a preventive or problem-oriented E/M visit by attaching modifier -25 to the E/M code for a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. If the patient reports for a biopsy and no other service is planned or conducted, however, the biopsy code is billed on its own, and no E/M service is reported.

The biopsy portion of 58558 is part of a larger procedure performed under anesthesia. The biopsy is taken intraoperatively during hysteroscopic surgery and may be interpreted while the patient is still in surgery. If the biopsy indicates malignancy, the surgeon may advance the procedure to include an excision of abnormal tissue/cells, or even a hysterectomy.

Other ICD-9 codes that may be reported to justify the endometrial biopsy (58100), in addition to the diagnoses listed above, include malignant neoplasm of body of corpus uteri (182.0), submucous leiomyoma of uterus (218.0), hypertrophy of labia (624.3), excessive or frequent menstruation (626.2) and irregular menstrual cycle (626.4). Diagnostic codes that support 58558 include malignant neoplasm of isthmus (182.1), benign neoplasm of corpus uteri (219.1), carcinoma in situ of cervix uteri (233.1), uteran neoplasm of uncertain behavior (236.0), endome-triosis of uterus (617.0) and hypertrophy of uterus (621.2).

Ovarian Biopsy An ovarian biopsy is the only way to conclusively diagnose ovarian cancer, which has the seventh highest cancer mortality rate in women. Consequently, once a lump or mass is detected on the ovary, it is removed surgically then biopsied intraoperatively. If pathology indicates malignancy, the surgeon may opt to continue the surgery to determine if the cancer has spread and may decide to remove one or both ovaries.

The code for ovarian biopsy is 58900 (Biopsy of ovary, unilateral or bilateral [separate procedure]). As a surgical procedure, this biopsy can be performed either through an open incision (laparotomy) or laparoscopically. If it is performed laparoscopically (49321, Laparoscopy, surgical; with biopsy [single or multiple]) and the intraoperative biopsy reveals malignancy, the surgeon may convert to an open procedure to remove the ovary(ies) (e.g., 58950,Resection of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentect-omy). At this point, most payers will consider the biopsy part of the more extensive procedure, but some may reimburse 58900 separately. If the work involved in obtaining the biopsy was significant and well-documented, modifier -22 (Unusual procedural services) paired with written documentation may help to obtain a higher reimbursement.

For 58900 or 49321, some of the more frequently reported diagnoses include malignant ovarian neoplasm (183.0), benign ovarian neoplasm (220), neoplasm of uncertain behavior of ovary (236.2), polycystic ovaries (256.4), ovarian endometriosis (617.1), ovarian follicular cyst (620.0), corpus luteum cyst of ovary (620.1), and other and unspecified ovarian cyst (620.2).

Vulvar Biopsy Vulvar biopsy is an office-based procedure that involves taking a sample of an abnormal mole, lesion or other dermatosa that does not respond to topical or other conventional treatments. With topical anesthesia, the biopsy sample is taken via shaving the lesion, excision, or puncturing the cyst or lesion and extracting a sample.

The CPT codes for vulva biopsy are 56605* (Biopsy of vulva or perineum [separate procedure]; one lesion) and +56606* ( each separate additional lesion [list separately in addition to code for primary procedure]). Code 56606 is an add-on code, and its definition indicates that it can be billed in multiples, for every lesion excised after the first one. Consequently, if a patient has three separate lesions biopsied, the claim form would read, line by line: