As minimally invasive gynecological surgery grows in numbers and popularity, you and your coders must become familiar with these new procedures to accurately report and receive reimbursement for these cases. Here's a look at the reimbursement issues surrounding some of the newer GYN procedures.

Hysteroscopy
Hysteroscopic approach is accomplished by passing a thin, telescope-like device (hysteroscope) that contains a small camera through the vagina and into the cervical os to gain entry into the uterine cavity. Hysteroscopy can be used to diagnose or treat a problem.

Abnormal uterine bleeding is one of the most common reasons to perform a diagnostic hysteroscopy. Report this using CPT code 58555 Hysteroscopy, diagnostic (separate procedure). Sometimes it's necessary to perform a surgical intervention during a diagnostic procedure. In such a case, you'd report only the surgical hysteroscopic code. Remember that surgical laparoscopy/hysteroscopy procedures include diagnostic laparoscopy/hysteroscopy, which you wouldn't report separately.

If a biopsy is obtained, a polyp removed or a dilatation and curettage (D&C) performed during a hysteroscopy, use 58558 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C.

Carefully analyzing the operative report will help you assign the correct CPT code from among the 4 listed here that identify surgical hysteroscopy procedures:

• 58559 Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method)
• 58560 Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)
• 58561 Hysteroscopy, surgical; with removal of leiomyomata (fibroid)
• 58562 Hysteroscopy, surgical; with removal of impacted foreign body

Endometrial ablation
Endometrial ablation, a less invasive alternative to a hysterectomy for treating abnormal/irregular uterine bleeding, can also be performed with a hysteroscope. Several variations are on the market today. Gynecare Thermachoice uses a small, silicone, fluid-filled balloon inserted into the uterus, which is heated gently. Novasure uses a slender surgical device inserted through the cervix into the uterus to deliver electrical energy. The Hydro ThermAblator System (HTA System) circulates a heated saline solution. The goal of these methods is to remove or ablate the uterine lining. Regardless of the methods used, the CPT code is 58563 Hysteroscopy, surgical; with endometrial ablation (endometrial resection, electrosurgical ablation and thermoablation, for example). Here's how endometrial ablation systems work:

• Under general or local anesthesia, a sheath containing the electrode (the part that does the ablation) is placed through the cervix. The sheath is pulled back, letting the electrode expand and conform to the shape of the uterine cavity.
• The system inflates the uterus with a small amount of CO2 to ensure proper placement of the device.
• The device is activated and automatically turns off when it senses that treatment is complete. Usually this takes about 90 seconds.
• After ablation is complete, the electrode safely retracts into the sheath for easy removal. Most women are ready to go home within an hour after the procedure.

Fallopian tube cannulation
As an alternative to laparoscopy sterilization, 2 new procedures for fallopian tube cannulation are available. These are called Essure and Adaina. During the hysteroscopy, inserts are placed just inside the fallopian tube. This stimulates the body's own tissue, which grows in and around the inserts. The scar tissue that is formed around the inserts occludes the tube. This is reported with 58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants, under ICD-9 Code V25.2 Admission for interruption of fallopian tubes or vas deferens.

Laparoscopic approach is another minimally invasive surgical technique. It is performed by passing a thin, lighted tube (laparoscope) through a small incision in the abdomen to look at the abdominal and gynecological organs. Ancillary trocars are inserted to allow delivery of surgical instruments.

Laparoscopic hysterectomy
A hysterectomy is one of the most frequently performed surgeries in the United States. Advances in laparoscopy techniques have made laparoscopic hysterectomy a minimally invasive alternative to abdominal hysterectomy. The procedures may be classified as total laparoscopic hysterectomy (TLH), laparoscopy with vaginal hysterectomy (LAVH) or laparoscopic supracervical hysterectomy (LSH). Correct billing and coding will depend on knowledge of how these different procedures are performed.

When a total hysterectomy is performed with only the assistance of a laparoscope, the uterus, adenexa and cervix are morsellized and removed with endoscopic tools, and the vaginal cuff is repaired endoscopically. This procedure is reported using CPT code range 58570 to 58573. Code selection is dependent on uterine weight and if the tubes and ovaries were removed. See "Coding Laparoscopic Hysterectomies" on page 13.

Robotic surgery
The newest category of MIS is robotic surgery. In 2000, the FDA approved the use of a robotic system (the da Vinci) for laparoscopy. Robotic surgery lets a surgeon sit at a computer console to control robotic arms that have "wrists" built into the end of the surgical tools and that move over the patient according to the surgeon's commands. Robotic-assisted surgery is the newest alternative to traditional open surgery and simply utilizes a different tool for accomplishing a laparoscopic procedure.

Unfortunately, there isn't a specific CPT code to describe robotic-assisted surgery — although there is a HCPCS code, S2900 Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure). Currently, there is no additional reimbursement for the physician using a robotic system by Medicare or the majority of commercial carriers. Code as if the physician were doing a standard laparoscopic procedure.