2007 PMCC Reproductive Systems, Delivery, and Maternal Care Chapter 15

1. 2007 PMCCReproductive Systems, Delivery, and Maternal Care Chapter 15

2. Chapter Outline Introduce students to Male anatomy and terminology Female anatomy and terminology Procedures performed on these systems

3. Male Genital System Code ranges are Penis (54000-54450) Testis (54500-54699) Epididymis (54700-54901) Tunica Vaginalis (55000-55060) Scrotum (55100-55180) Vas Deferens (55200-55450) Spermatic Cord (55500-55559) Seminal Vesicles (55600-55680) Prostate (55700-55899)

4. Penis (54000-54450) Penis consists of three parts Root, body, glans penis At distal aspect—Skin of the penis folds over itself forming protective prepuce or foreskin Incision (54000-54015) When patient diagnosed with gonococcal infection (acute/chronic), balanoposthitis, other inflammatory disorders of penis or vascular disorders of penis Provider may perform deep incision and drainage of penis Once deep abscess or hematoma diagnosed Provider drains it by incising penile tissue Drain is often left in place to assure adequate drainage Use CPT code 54015

5. Destruction (54050-54065) Electrosurgery (54055), Cryosurgery (54056), Chemical destruction (54050), Laser (54057), Other methods Used for destruction of lesions on the penis Lesions include Condyloma—a wart-like growth Papilloma—a benign skin tumor Molluscum contagiosum—small, white, firm, raised lesions Herpetic vesicle—blister from a herpes virus

6. Excision (54100-54164) Revised codes for 2007 54150 Circumcision, using clamp or other device with regional dorsal penile or ring block 54160 Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less) 54161 older than 28 days of age All three codes revised to more specifically describe age of patient Code 54150 further revised to specify type of penile block provided Append modifier 52 to code 54150 if performed without a nerve block

7. Introduction (54200-54250) Penile plethysmography, and nocturnal penile tumescence and/or rigidity test (54240, 54250) Have technical and professional component Careful reporting required to identify which procedures are performed In hospital and in office setting Use code 54240 When provider is measuring physiological potential of the penis to attain and maintain an erection Use code 54250 When nighttime erection in an impotent patient during rapid eye movement sleep is monitored to determine cause of impotence

8. Repair (54300-54440) Code 54304—used to correct conditions such as hypospadias and congenital chordee For second stage hypospadias repair See codes 54308-54316 Code 54340—reports repair of hypospadias complications If procedure requires mobilization of skin flaps and urethroplasty with flap or patch graft, use code 54344 If procedure requires extensive dissection, use code 54348

9. Testis (54500-54699) Testes Lie in scrotal sac with left testis somewhat lower than the right Pendulous placement of the testes is necessary in order to cool arterial blood that promotes Sperm production, prevents damage due to heat Excision (54500-54535) Partial orchiectomy—54522 Radical orchiectomy (inguinal approach)—54530 Radical orchiectomy (with abdominal exploration)--54535

10. Testis (54500-54699) Exploration—New Subheading for 2007 Code 54550 and 54560—exploration of undescended testicle only Repair (54600-54680) Orchiopexy—surgical fixation of an undescended testicle into the scrotum Incision can be made in inguinal area or in skin fold by thigh and lower abdomen area Once undescended testicle located, can be brought down through inguinal canal and into scrotum Use code 54640 Laparoscopy (54690-54699) Code 55550—surgical laparoscopy with ligation of spermatic veins for varicocele

11. Epididymis (54700-54901) Epididymis and vas deferens make up System of tubes that provide maturation, storage and transportation of sperm Cilia within epididymis Promote transfer of sperm in the absence of muscle Sterilization in the male—vasectomy Accomplished by clipping, severing, ligating the vas deferens Incision (54700) This procedure often performed with another separately identifiable procedure Coder should code major procedure first

12. Epididymis (54700-54901) Excision (54800-54861) Epididymectomy (54860-54861) May be performed on patient diagnosed with Malignant neoplasm of epididymis Carcinoma in situ of other male genital organs Unspecified orchitis Code 54860, for unilateral Code 54861, both sides

13. Epididymis (54700-54901) New codes for 2007 54865 Exploration of epididymis, with or without biopsy Since the exploration code 54820 is not an excisional code New subheading titled “Exploration” has been added to the Epididymis subsection to encapsulate codes that describe exploration without excision A cross-reference has been added to direct users from deleted code 54820 to the exploration code 54865

14. Tunica Vaginalis (55000-55060) Thin pouch that holds testes within scrotum In the fetus Tunica vaginalis is formed in the abdomen and then migrates into scrotum with the testes After pouch is in the testes, seals off from the abdomen Excision (55040-55041) Hydrocele—common intrinsic scrotal mass Often results from excessive accumulation of sterile fluid with tunica vaginalis due to overproduction or diminished reabsorption Can appear as painless scrotal swelling that can be transilluminated Can be communicating or noncommunicating Code 55040 for unilateral; code 55041 for bilateral

15. Scrotum (55100-55180) Scrotum—skin covered sac that lies below pubic bone Lower portion of spermatic cord, epididymis, and testes are contained in this sac Each side contains a testis, an epididymis, and a spermatic cord Muscles in the scrotum (cremasteric muscles) Move testicles slightly within scrotum depending on surrounding temperature Repair (55175-55180) Use code 55175 When surgeon repairs a defect and/or developmental abnormality of the scrotum by simple wound revisions and/or creations

16. Vas Deferens (55200-55450) Vas deferens—coiled tube that carries the sperm out of the testes Incision (55200) Vasotomy code is component of more complex service Usually not identified separately Bilateral code is reported once even if procedure is performed on both sides

17. Spermatic Cord (55500-55540) Spermatic cord includes Arteries and veins circulating blood to/from testes and other structures in the scrotum These structures together support the testicles in the scrotum Tip: Spermatic cord is not severed during vasectomy. A varicocele is caused by incompetent or inadequate valves within veins along the spermatic cord. They usually develop slowly and are asymptomatic. Higher incidence in men between 15-25 years old

18. Seminal Vesicles (55600-55680) Seminal vesicles—hollow pair of muscular organs situated between the posterior bladder wall and the rectum Produce a fluid that provides nutrients for sperm and lubricates the urethra Fluid mixes with other fluids to create semen Excision (55650-55680) Vesiculectomy (code 55650) For removal of one of the seminal vesicles that lies behind urinary bladder If performed bilaterally, append modifier 50

19. Prostate (55700-55899) Prostate—walnut-sized gland that lies below the urinary bladder and surrounds the urethra Produces a fluid, called prostatic fluid, that contains, protects, nourishes, and supports the sperm This fluid forms most of the volume of the semen Has no known function other than reproduction Also source of PSA that is used as blood test to detect prostate cancer

20. Incision (55700-55725) Code 55700—biopsy of the prostate Surgeon collects tissue from the prostate for analysis May be done by needle or punch biopsy If done by needle Needle inserted into prostate guided by index finger or ultrasound and needle biopsy sheath is advanced over needle and twisted off to shear off a sample For incisional biopsy, see code 55705

21. Excision (55801-55865) Retropubic radical prostatectomy, with or without nerve sparing—code 55840 Surgeon may use to remove prostate gland Patient is catheterized Incision made in lower abdomen just above pubic area Entire gland with capsule intact, seminal vesicles and portions of vas deferens are removed by freeing the prostate Suturing to newly created bladder outlet is done to repair transected urethra

22. Excision (55801-55865) New codes for 2007 55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy Code 55859 has been deleted and renumbered to code 55875 without a change in the code terminology to correct the assumption that this was an excisional procedure, due to its placement under the Excision subheading of the Prostate subsection. Code 55875 is now correctly located under the Other Procedures subheading of the Prostate subsection

23. Female Genital System Code ranges are as follows Vulva, Perineum and Introitus (56405-56821) Vagina (57000-57425) Cervix Uteri (57452-57800) Corpus Uteri (58100-58579) Oviduct/Ovary (58600-58770) Ovary (58800-58960) In Vitro Fertilization (58970-58999)

24. Vulva, Perineum, and Introitus (56405-56821) External genitalia for the female Vulva (labia majora and minora) Mons veneris (mons pubis) Clitoris Fourchet Vestibule Vestibular bulb Fossa navicularis External opening of vagina (introitus) Hymen

25. Vulva, Perineum, and Introitus (56405-56821) Incision (56405-56442) Code 56405—Incision and drainage of vulvar or perineal abscess Code 56442—Hymenotomy, simple incision New for 2007 Established to replace deleted code 56720, which had been incorrectly placed under the Excision subheading in the Vulva, Perineum, and Introitus subsection Now correctly located under the Incision subheading in the Vulva, Perineum, and Introitus subsection Destruction (56501-56515) Chemicals, electrosurgery, cryosurgery, or laser May be used to destroy vulvar lesions Read operative note carefully to ascertain if lesion was destroyed, excised or removed during repair procedure Note that number of lesions does not affect code selection

26. Vulva, Perineum, and Introitus (56405-56821) Excision (56605-56740) Majority of procedures listed in this section describe different levels of a vulvectomy (56620-56640) Simple—removal of skin and superficial subcutaneous tissue Radical—removal of skin and deep subcutaneous tissue Partial—removal of less than 80% of vulvar area Complete—removal of greater than 80% of vulvar area

27. Vulva, Perineum, and Introitus (56405-56821) Repair (56800-56810) Code 56800—plastic repair of introitus Performed to repair and restore the anatomy of the vaginal opening Code 56805—requires presence of congenital anomaly Surgeon reduces the size of an enlarged clitoris Endoscopy (56820-56821) Reported by a number of CPT codes Several include biopsy at same time as exam Colposcopy of vulva (56820), with biopsy (56821) Colposcopy of vagina (57420), with biopsy (57421) Colposcopy of cervix (57452-57461)

28. Vagina (57000-57425) Vagina Forms canal from vaginal orifice through the vestibule to the uterine cervix Incision (57000-57023) Code 57000—colpotomy; with exploration Incision made into wall of vagina for examination If abscessed drained during same session , use code 57010 Code 57022—Incision and drainage of an obstetrical/postpartum vaginal hematoma Code 57023—I&D of hematoma of vagina (nonobstetric)

29. Vagina (57000-57425) Destruction (57061-57065) Code for destruction of vaginal lesions Based on whether surgeon considered the destruction, simple or extensive Simple destruction—code 57061 When lesions are few in number, small or simple Extensive destruction—code 57065 When lesions are numerous, large or difficult Excision (57100-57135) Code 57100—simple biopsy Separate procedure In most instances it would not be reported separately Code 57106—partial vaginectomy

30. Vagina (57000-57425) Introduction (57150-57180) Codes describe introduction of foreign materials into the vagina for medicinal or contraceptive purposes Code 57155—Insertion of uterine tandems and/or vaginal ovoids for clinical brachytherapy Repair (57200-57335) Repair of cystocele and rectocele by colporrhaphy (code 57260) Involves plastic repair of vagina and the fibrous tissue separating the bladder, vagina and rectum

31. Vagina (57000-57425) Manipulation (57400-57415) Patients required to be under anesthesia General, Epidural, Spinal If performed without anesthesia Appropriate E/M code should be reported Code 57410—pelvic exam under anesthesia Do not report if surgeon performing another major gynecological surgical procedure during same session Endoscopy (57420-57425) Code 57454—Used when cervical biopsy and/or endocervical curettage performed at time of colposcopy Code 57460—when biopsy of cervix performed using loop electrode at same encounter as colposcopy

32. Cervix Uteri (57452-57820) Uterus—pear-shaped organ that opens into the vagina Fundus—rounded top of uterus Corpus—main upper body Cervix—lower, narrow neck Lower third of uterus also known as cervix uteri Upper two-thirds portion of body of uterus called the corpus uteri

33. Cervix Uteri (57452-57820) Excision (57500-57556) Biopsy or local excision of cervical lesion (code 57500) Involves removing a small piece of superficial cervical tissue (exocervix cells) Code 57520 Used when conization is performed with cold knife or laser Performed with/without fulguration, with/without dilation and curettage Trachelectomy (57530) Amputation of cervix Repair (57700-57720) Cerclage—sutures being used to close the cervix Code 57700—for non-pregnant patients Codes 59320 and 59325—for pregnant patients

34. Cervix Uteri (57452-57820) Manipulation (57800) Code 57800—dilation of the cervical canal, instrumental Dilator is inserted into endocervix and passed up through the cervical canal Separate procedure Report only when performed independently or when unrelated to primary procedure during same encounter or operative session Use modifier 59, when performed with another procedure or service

35. Corpus Uteri (58100-58579) Excision (58100-58294) Code 58120—dilation and curettage (D&C) Hysterectomy codes 58150-58294 Codes based on approach used and surgical level Introduction (58300-58356) Code 58350—chromotubation Often reported with the diagnostic terms Chronic salpingitis and oophoritis Acute parametritis Pelvic cellulitis Acquired atrophy of ovary and fallopian tube Female infertility of tubal origin

36. Corpus Uteri (58100-58579) Repair (58400-58540) Hysterorrhaphy—involves suturing of uterus (womb) Code 58520 Reported when repair is performed on nonpregnant uterus Code 58540 Surgeon completes plastic repair of malformed uterus Performed on patients to adjust an anomaly present from birth and not from conditions due to trauma/disease

37. Corpus Uteri (58100-58579) Five new codes for 2007: 58541-58544 and 58548 were established to Describe various laparoscopic hysterectomy procedures Codes 58541-58544 describe laparoscopic supracervical hysterectomy Included components of 58541-58544 Pelvic examination under anesthesia (57410) Laparoscopy with or without collection of specimens (49320), myomectomy with excision of one to four myomas (58140) Total abdominal hysterectomy (58150) Laparoscopic removal of adnexal structures (58661) Laparoscopic fulguration of oviducts (58670) Laparoscopic occlusion of oviducts by a device such as a band or clip (58671)

38. Oviduct/Ovary (58600-58770) Fallopian Tubes Pair of ducts opening at one end into the uterus and at other end into peritoneal cavity, over the ovary Each tube serves as passage through which the ovum is carried to uterus and through which spermatazoa move out towards the ovary Infundibulum flares and is covered by fimbriae that draw the ovum in a wave-like motion into tube for fertilization Fimbriae Draped in a finger-like protection from the infundibulum over the ovary Ampulla is proximal to the infundibulum and connected to the fundus of the uterus by the isthmus Fallopian tubes held in place by ligaments

39. Incision (58600-58615) Codes in this section describe tubal ligation Codes identify the method used Abdominal Vaginal Laparoscopic Codes also identify Whether tubal follows a delivery (vaginal or cesarean) Tubal ligation--generally requires transecting or occluding both fallopian tubes, unless one removed in previous surgery Code 58700—salpingectomy, complete or partial, unilateral or bilateral, separate procedure

40. Laparoscopy (58660-58679) Code 58660 Laparoscopy, surgical, with lysis of adhesions Code 58740 Lysis of adhesions (salpingolysis, ovariolysis) Performed to restore fertility Should not be used for freeing of the tube and ovary as part of another procedure

41. Ovary (58800-58960) Ovary—gland that produces reproductive cells, the ovum, and two hormones Ovaries—pair of oval-shaped organs that lie within female pelvis and function to produce female sex hormones and ova (eggs) Each ovary is located at lateral aspect of uterus adjacent to the infundibulum of each fallopian tube During female’s reproductive years 300-400 follicles mature and leave the ovary during ovulation Mature ovarian follicles secrete estrogen and progesterone

42. Incision (58800-58825) Cyst—sac containing fluid or semisolid material Code 58800 Used when surgeon drains a cyst on one or both ovaries, through incision in the vagina Code 58805 Based on abdominal approach Once incision is made, cyst is ruptured using a surgical instrument, electrocautery or laser

43. Excision (58900-58960) Revised code 58950 Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; Revised to include the term “initial” in the descriptor to differentiate the initial resection of an ovarian, tubal, or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy from the recurrent resection described by codes 58957 and 58958 Revision also extends to codes 58951 and 58952 Inclusion of the term “initial” is intended to Emphasize that the primacy of this procedure refers only to the timing of the surgery rather than the classification of the malignancy

44. In Vitro Fertilization (58970-58976) When surgeon performs follicle puncture for oocyte retrieval, by any method Surgeon is aspirating a mature or nearly mature egg from its follicle for in vitro fertilization Procedure may be done by laparoscope or percutaneously with ultrasound Code 76948, ultrasonic guidance for aspiration of ova Usually performed with code 58970

45. Maternity Care and Delivery (59000-59899) This section describes antepartum and postpartum services, including delivery Antepartum—period of time between conception and the beginning of labor Puerperium—period of time from the termination of labor to complete involution of the uterus, usually defined as 42 days Postpartum—period of time, approximately six weeks, after birth

46. Antepartum Services (59000-59076) Amniocentesis (59000-59001) Ultrasound guidance (76946) used when performing this procedure Procedure usually performed between 16-18 weeks of gestation Can be performed as early as 12 weeks up to term Code 59000—Includes surgical procedure only Code 59001—Therapeutic amniocentesis performed to reduce fluid volume Includes ultrasonic guidance For amniotic fluid scan—code 82143

47. Cordocentesis and Chorionic Villus Sampling (59012-59015) Cordocentesis—procedure used to sample fetal blood drawn from umbilical vein where it joins the placenta Sample may be studied to manage hemolytic diseases or genetic abnormalities Code 59015 Used to procure chorionic villus sample for early diagnostic information regarding the fetus

48. Fetal Test and Blood Sampling (59020-59030) Code 59020—fetal contraction stress test Designed to observe the fetal heart rate during stress Fetal nonstress test (NST) Nonivasive test that monitors fetal heartbeat during fetal movement Biophysical profile (code 76818) includes a NST Not appropriate for NST during labor if done solely to monitor fetal heart rate Four codes (59070-59076) Describe fetal procedures designed to diagnose and treat anomalies in utero that would jeopardize health and mortality of live-born infant or result in stillborn birth

49. Introduction (59200) Cervical ripening may be initiated prior to labor for Induced abortion or Prior to other procedures that require cervical dilation Code 59200—separate procedure Describes insertion of a cervical dilator Dilators are inserted 6-12 hours prior to need for dilated cervix Code 59200 may be reported with Codes 59840-59841 (induced abortion) Do not report with codes 59855-59857

50. Repair (59300-59350) Provider other than attending provider may report Episiotomy or other vaginal/cervical repair (code 59300) that may be required after delivery Codes 59320-59325—cerclage of cervix Include removal of the suture at or before delivery Should not be reported separately

51. Vaginal Delivery, Antepartum, and Postpartum Care (59400-59430) Number of antepartum visits Varies although average patient will have approximately 13 antepartum visits Initial and subsequent history, exam, weight, BP, FHTs, routine UAs Performed during these visits When patient develops complication during antepartum period Additional visits may be reported Should be coded as E/M codes at appropriate level

52. Vaginal Delivery, Antepartum, and Postpartum Care (59400-59430) Unrelated visits during antepartum period May be due to conditions unrelated to pregnancy These services can be reported at time of service using E/M codes; use medical condition a primary diagnosis When reporting normal ante- and postpartum care with uncomplicated pregnancy, including vaginal delivery Use code 59400 as total OB care When reporting vaginal delivery only—code 59409 Including postpartum care, use code 59410

53. Vaginal Delivery, Antepartum, and Postpartum Care (59400-59430) Code 99346—physician’s attendance at delivery to prepare for delivery of newborn that may require intervention or resuscitation at birth Includes initial stabilization of newborn Reported if provider provided services prior to, during, and immediately after delivery of newborn

54. Vaginal Delivery, Antepartum, and Postpartum Care (59400-59430) Partial Obstetrical Services If provider does not provide all services defined in global codes Provider may report services performed using 59425 or 59426 (antepartum care) Specific delivery codes and/or 59430 (postpartum care) Cesarean Delivery (59510-59525) Code 59510 Used to report global service Code 59514—delivery only by cesarean Code 59515—delivery and postpartum care

55. Abortion (59812-59857) Abortion can be Spontaneous (miscarriage), therapeutic, voluntary Major methods for terminating pregnancy Medical or surgical When coding, identify Trimester, type, method, stage of abortion Codes 59840 and 59841 Predominantly used to report elective or therapeutic termination of pregnancy Since pregnancy ends at moment of abortion Prenatal visits prior to are no longer considered part of global package

56. Other Procedures (59866-59899) For removal of cerclage suture under anesthesia Report code 59871 Example of using unlisted code 59899 Amnioinfusion catheter was inserted into the vagina for infusing solution for a meconium staining Submit copy of operative report

57. The End