Expert Commentary

Recent NCCI edits have significantly impacted billing and reimbursement for vaginal hysterectomy

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ACOG and AUGS, with input from other medical societies, are in discussions with the National Correct Coding Initiative and CMS to reverse the edits


The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control what it considers to be duplicative and improper coding of multiple procedures performed in a single setting in Part B claims.

Since 1996, Medicare has used NCCI edits to limit additional payments for two procedures that were thought to be similar because of anatomic and temporal considerations. For example, billing for both lysis of adhesions and total abdominal hysterectomy in the same operation has long been denied, as preoperative and postoperative care typically are the same and the intraservice times are not appreciably different. Both require opening and closing of the same incision, and so on.

The most recent set of NCCI edits, effective October 1, 2014, “bundles” procedures for high uterosacral vaginal vault suspension (also known as vaginal colpopexy—intraperitoneal approach—CPT code 57283) and combined colporrhaphy (code 57260) when they are performed at the same time as a vaginal hysterectomy. Previously, these procedures could be billed together and separately paid for by Medicare, although the additional procedures were subjected to a -51 modifier, designating multiple procedures, which reduced the payment for them by approximately 50%.

How the NCCI makes its determinations
The NCCI develops coding policies, or “edits,” by analyzing coding conventions and reviewing standard medical and surgical practices. It reviews current coding practices and guidelines developed by national societies, such as the American College of Obstetricians and Gynecologists (ACOG), but the NCCI has the power to decide what surgical procedures get “bundled” with other procedures that commonly are performed in the same setting. As a general rule, the NCCI feels that procedures performed through the same incision, in close anatomic proximity, and by the same surgeon should not be billed separately. The NCCI develops and implements its coding edits on a quarterly basis, after notifying the medical societies most likely to be affected by the new bundles and soliciting feedback.

As gynecologic surgeons, we are familiar with the multitude of bundles that already exist for abdominal and laparoscopic procedures—lysis of adhesions, ureterolysis, abdominal enterocele repair, removal of both tubes and ovaries (as opposed to unilateral salpingo-oophorectomy)—which have been around for decades. However, until recently, vaginal surgical procedures were not bundled but were billed “a la carte.”

Because the October 1 edits deny separate payment when combined colporrhaphy and high uterosacral vaginal vault suspension are performed alongside vaginal hysterectomy, gynecologic surgeons now get paid only for the vaginal hysterectomy. These edits are likely to have a profound impact on practicing vaginal surgeons, especially subspecialists in female pelvic medicine and reconstructive surgery.

Procedures that can no longer be billed when performed at the same time as a vaginal hysterectomy include:

  • combined anterior and posterior colporrhaphy (code 57260)
  • abdominal sacrocolpopexy (57280)
  • extraperitoneal vaginal colpopexy (eg, sacrospinous ligament suspension, or SSLS, 57282)
  • intraperitoneal vaginal colpopexy (eg, high uterosacral ligament suspension, 57283)
  • abdominal paravaginal repair (57284).

For a full version of current edits, see the CMS Web site at

AUGS, ACOG, and others respond to the edits
Since implementation of the ­October 1 edits, both ACOG and the American Urogynecologic Society (AUGS) have received numerous complaints and protests from members. Both societies reviewed and strongly disagreed with the proposed edits before their implementation, but NCCI ultimately decided to implement them.

In cooperation with ACOG and several other national medical societies, such as the Society for Gynecologic Surgeons and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, AUGS formed a task force that already has engaged CMS in a series of communications focused on changing or reversing some of these edits.

This task force, under the leadership of AUGS, believes that CMS and NCCI do not fully understand the complexity of vaginal reconstruction performed for advanced pelvic organ prolapse, or the fact that vaginal hysterectomy is an extirpative procedure that often is required to facilitate the more time-consuming reconstructive procedures. Furthermore, the reconstructive procedures require separate entry and closure of different surgical spaces (eg, rectovaginal, vesicovaginal). In addition, the surgical risks and postoperative care often are more complex than they are when a simple vaginal hysterectomy is performed for benign gynecologic indications other than pelvic organ prolapse.

Thus far, both NCCI and CMS have listened to our objections, indicated that they understand them, and agreed to reexamine the appropriateness of the bundles. As of press time, however, CMS has not announced any plans to change or reverse any of these edits.

The October 1 edits are not the only ones that adversely affect the gynecologic surgeon. As of ­January 1, 2015, NCCI and CMS implemented another set of edits that no longer allow separate billing and reimbursement for cystoscopy (52000) performed at the time of pelvic surgery, when the purpose of the procedure is to assure the surgeon that the ureters and urinary bladder are free of injury. However, cystoscopy may be billed separately when the primary purpose differs from that scenario.

ACOG and AUGS intend to stay in discussion with CMS regarding the appropriateness of the most recent edits. If any edits are reversed, the decision will be retroactive to the October 1, 2014, date. Stay tuned for the final decision.

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