Best options, teChniques, anD CoDing tips for Pelvic ...

1 Supplement to Available at September 2007. best options , techniques, and CoDing tips for Pelvic prolapse repair O. n Program Chair ptions for treatment of Pelvic floor prolapse Barbara S. Levy, MD. Medical Director, Women's Health Center continue to evolve; however, questions regard- Franciscan Health System Federal Way, WA ing the etiology of prolapse remain unanswered. Dr Levy serves on the OBG Management Board of Editors. Clearly related to such factors as childbirth and the aging process,1,2 prolapse is likely to become of greater con- n Faculty cern to clinicians as the population of women aged 60. Patrick Culligan, MD. Director, Division of Urogynecology and Pelvic Reconstructive Surgery years and older Its incidence is expected to Atlantic Health Systems Morristown, NJ reach or exceed 30% in this The demand for gynecologic services likely will increase by more than G.

2 Willy Davila, MD 45% in the next 10 prolapse is also associated Chairman, Department of Gynecology Head, Section of Urogynecology and Reconstructive Pelvic Surgery with defects in collagen and smooth-muscle structure Cleveland Clinic Florida Weston, FL. and 12 Tissue may weaken in response to phys- ical activity13 or increased intra-abdominal pressure from Robert Harris, MD. Urogynecologist chronic constipation, chronic cough, chronic obstructive Women's Specialty Center Jackson, MS pulmonary disease, or This roundtable discussion among experts examines Vincent Lucente, MD the medical evidence regarding the etiology and man- Chief of Gynecology, St. Luke's Health Network, Lehigh Valley, PA.

3 Chief, Section of Female Pelvic Medicine and Reconstructive Surgery agement of prolapse , evaluates currently available treat- Abington Memorial Hospital, Abington, PA. Medical Director, The Institute for Female Pelvic Medicine ments, and describes emerging trends. tips on CoDing , and Reconstructive Surgery, Allentown, PA. provided by Melanie Witt, RN, CPC-OGS, MA, accom- Dennis Miller, MD. Urogynecologist pany the narrative. Milwaukee Urogynecology Wheaton Franciscan Medical Group Wauwatosa, WI. Dr Levy: What evidence supports our current procedures? Melanie Witt, RN, CPC-OGS, MA Dr Culligan: The best evidence for traditional suture- Independent CoDing and documentation consultant Former program manager, Department of CoDing and Nomenclature based repairs consists of large case series reported by in- American College of Obstetricians and Gynecologists Ms Witt writes the Reimbursement Advisor column in OBG Management.

4 Dividual surgeons. These are often marred by poor rates of success, poorly standardized definitions of success and failure, and less-than-ideal follow-up. The failure rate for This publication was developed under a grant from the Pelvic Health Coalition. anterior suture-based repairs approaches 50% or 2007 Dowden Health Media Supplement to OBG Management n September 2007 S . best options , techniques, and CoDing tips for Pelvic prolapse repair CoDing issues for clinicians science in which evaluation of outcomes is most important. Therefore, evaluation of tissue quality Clinical question: We report diagnostic codes for patients with is essential. Endogenous tissue may be insufficient varying types of prolapse and symptoms.

5 Denials for services often note that a medically justified reason for the procedure or of poor quality; its use will result in a high rate was not provided. Why? of recurrence. The evolving science has provided good data on the use of graft materials to augment Answer: Increasingly sophisticated payers and claims pro- cessing software determine if the primary diagnosis is an ap- repairs. proved medically justifiable indication for the surgery billed, The technique for sacral colpopexy is very uni- based on both the code and its order. form. Similar standards in newer procedures are Two ICD9 diagnostic codes cover cystocele: (Cysto- evolving, along with improved diagnostic skills to cele, midline) and (Cystocele, lateral).

6 Paravaginal de- accurately identify defects that require correction. fect repair 's correct medically justifiable diagnosis is , not Many payers look for codes for existing fascial Repeat procedures: weakness and why mesh is required to establish medical ne- cessity. To avoid denials, link mesh add-on code 57267 to Why do original repairs fail? (Incompetence or weakening of pubocervical tissue; Dr Levy: Our maturing patient base allows us to ad- anterior compartment) or use (Incompetence or weak- vance the science. A patient may have had a repair ening of rectovaginal tissue; posterior compartment). Code at age 50 years and a recurrence at age 70. We are 57267 specifically addresses only the anterior and posterior compartments; only codes and establish medi- learning about the longevity of our repairs.

7 Women cal necessity. with genetic collagen disorders seem to experience recurrence much earlier than do other women. For colpopexy, ICD9 code ( prolapse of vaginal vault af- ter hysterectomy) links to a colpopexy code for vaginal vault Dr Lucente: Certainly, many women outlive the for prolapse after hysterectomy. If vaginal vault prolapse is original suture repair . Obesity and its effect on stress corrected, but the uterus intact, the code is (Other pro- loads will also increase the incidence of prolapse . lapse of vaginal walls without mention of uterine prolapse ). Dr Culligan: As we develop our discussion, it may Diagnostic code order supports medical necessity. Lists of be helpful to think about failures occurring at 2.

8 Criteria for procedures may represent actual defects; codes peaks in time: an early peak and a late-term peak. for general symptoms are accepted as secondary clarification. If a patient requires surgery to correct stress urinary incon- Treatment decisions should be based on the possi- tinence (SUI, ) from intrinsic sphincter deficiency (ISD, bility of early failure. Shull's suture-based studies19. ), ISD not SUI is the primary diagnosis; the abnor- and my study on abdominal sacral colpopexy21. mality represents a specific physical defect. Urinary inconti- had at least 5 years' follow-up. Both investigations nence is viewed as an accompanying symptom. In fact, ICD9. guidelines allow only the diagnosis code or other in- showed that roughly 96% of failures occur within continence symptom codes ( ) to be reported as 2 years.

9 A secondary diagnosis when a more definitive diagnosis has Dr Levy: Why do traditional suture-based proce- been reported. Melanie Witt, RN, CPC-OGS, MA. dures fail? What about attachments and the forces to which these tissues are subjected? DeLancey is Posterior repairs have had better Consid- doing a significant amount of work in this ered in isolation, suture-based apical suspension has a Dr Davila: Typical defects involve apical transverse higher rate of separations of the fascia, both anteriorly and poste- Dr Miller: Procedures such as sacrospinous vault re- riorly. When we reattach the fascia to the apex, and pair show good clinical outcomes specific to the apex, the apex is well supported, the repairs are likely to but they may result in increased vulnerability and fail- be successful.

10 Ures in the other Integrated repairs Still, a central issue remains: Even if we repair using graft materials may offer more overall success the anatomy perfectly, weak endogenous tissue (and without alternate site failures. most defects are very obvious during intraoperative Dr Davila: We are seeing the transformation of recon- dissection) may deteriorate rapidly, causing recur- structive surgery from an art in which procedures rent fascial or connective tissue separation from the compensate for and repair structural defects to a apex. Both anterior and posterior connective tissue S September 2007 n Supplement to OBG Management repairs using good tissue result in good median- CoDing issues for clinicians term outcomes.