Surgical Techniques

Cesarean scar defect: What is it and how should it be treated?

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Evaluation and treatment

Patients presenting with the symptoms de-scribed above who have had a prior cesarean delivery should be evaluated for a cesarean scar defect.9 The best time to assess for the abnormality is after the patient’s menstrual cycle, when the endometrial lining is at its thinnest and recently menstruated blood has collected in the defect (this can highlight the niche on imaging). Transvaginal ultrasonography (FIGURE 3) or saline-infusion sonohysterogram serve as a first-line test for in-office diagnosis.7 Magnetic resonance imaging (MRI), 3-D ultrasonography, and hysteroscopy are additional useful imaging modalities that can aid in the diagnosis.

Treatments for cesarean scar defect vary dramatically and include hormonal therapy, hysteroscopic resection, vaginal or laparoscopic repair, and hysterectomy. Nonsurgical treatment should be reserved for women who desire a noninvasive approach, as the evidence for symptom resolution is limited.8

To promote fertility and decrease symptoms, the abnormal, fibrotic tissue must be removed. In our experience, since 2003, we have found that use of a laparoscopic approach is best for women desiring future fertility and that hysteroscopic resection is best for women whose childbearing is completed.9 Our management is dictated by the patient’s fertility plans, since there is concern that cesarean scar defect in a gravid uterus presents a risk for uterine rupture. The laparoscopic approach allows the defect to be repaired and the integrity of the myometrium restored.9

What are the coding options for cesarean scar defect repair?

Melanie Witt, RN, CPC, COBGC, MA

As the accompanying article discusses, the primary treatment for a cesarean scar defect depends on whether the patient wishes to preserve fertility, but assigning a procedure code for either surgical option will entail reporting an unlisted procedure code.

Under Current Procedural Terminology (CPT) guidelines (which are developed and copyrighted by the American Medical Association), procedure code selected must accurately describe the service/procedure performed rather than just approximate the service. This means that when a procedure-specific code does not exist, an unlisted procedure code that represents the type of surgery, the approach, and the anatomic site needs to be selected.

When an unlisted CPT code is reported, payment is based on the complexity of the surgery, and one way to communicate this to a payer is to provide additional documentation that not only includes the operative report but also suggests one or more existing CPT codes that have a published relative value unit (RVU) that approximates the work involved for the unlisted procedure.

The coding options for hysteroscopic and laparoscopic treatment options are listed below. The comparison codes offered will give the surgeon a range to look at, but the ultimate decision to use one of those suggested, or to choose an entirely different comparison code, is entirely within the control of the physician.

ICD-10-CM diagnostic coding

While the cesarean scar defect is a sequela of cesarean delivery, which is always reported as a secondary code, the choice of a primary diagnosis code can be either a gynecologic and/or an obstetric complication code. The choice may be determined by payer policy, as the use of an obstetric complication may not be accepted with a gynecologic procedure code. From a coding perspective, however, use of all 3 of these codes from the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) paints the most accurate description of the defect and its cause:

  • N85.8 Other specified noninflammatory disorders of uterus versus
  • O34.21 Maternal care for scar from previous cesarean delivery plus
  • O94 Sequelae of complication of pregnancy, childbirth, and the puerperium.

Hysteroscopic resection codes:

  • 58579 Unlisted hysteroscopy procedure, uterus
  • The codes that may most closely approximate the physician work include 58561 (Hysteroscopy, surgical; with removal of leiomyomata) with 15.48 RVUs or 58560 (Hysteroscopy, surgical; with division or resection of intrauterine septum [any method]) with 10.92 RVUs.

Laparoscopic repair codes:

  • 58578 Unlisted laparoscopy procedure, uterus
  • The codes that may most closely approximate the physician work include 58520 (Hysterorrhaphy, repair of ruptured uterus [nonobstetrical] 24.25 RVUs or 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method) with 20.14 RVUs.

You may also want to report a diagnostic hysteroscopy (code 58555), but keep in mind that payment will depend on documentation that clearly indicates that the use of the hysteroscope was for diagnostic purposes. Use of the hysteroscope to simply identify the surgical site to be repaired via the laparoscope will usually not be reimbursed separately.

Ms. Witt is an independent coding and documentation consultant and former program manager, department of coding and nomenclature, American Congress of Obstetricians and Gynecologists.

The author reports no financial relationships relevant to this article.

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