Managing a Pessary Business - Society of Urologic Nurses and

SERIES
Managing a Pessary Business
SPECIAL SERIES
ON
PESSARIES
Katharine O’Dell, Leslie Saltzstein Wooldridge, and Shanna Atnip
T
his article discusses topics important to developing an effective pessary practice, including
a review of office management
options related to fitting, stocking, and maintaining pessaries,
and compliance issues related to
appropriate billing and coding.
© 2012 Society of Urologic Nurses and Associates
O’Dell, K., Wooldridge, L.S., & Atnip, S. (2012). Managing a pessary business.
Urologic Nursing, 32(3), 138-146.
In this final article in a series of three, components of pessary fitting, provision,
and follow up are reviewed from a business perspective related to supplies,
patient flow, billing, and coding.
Key Words:
Pessary Fitting and Stocking
Decisions
To initiate pessary services,
providers must develop an overall plan for fitting and dispensing
these devices. Figure 1 offers an
overview of typical options that
will need to be considered and
their relationships to the develKatharine O’Dell, PhD, CNM, WHNP-BC,
is an Assistant Professor of OB/GYN, the
Division of Pelvic Medicine and
Reconstructive Surgery, UMass Memorial
Medical Center, Worcester, MA.
Leslie Saltzstein Wooldridge, MSN, GNP,
BCIA, F-AGS, is a Nurse Practitioner and
the Director the Bladder Control Center,
Muskegon, MI.
Shanna Atnip, MSN, WHNP-BC, is a Nurse
Practitioner, the Division of Urogynecology
and Reconstructive Pelvic Surgery,
Parkland Health & Hospital System, and the
University of Texas Southwestern Medical
Center, Dallas, TX.
Note: Objectives and CNE Evaluation Form
appear on page 146.
Statements of Disclosure: Leslie Saltzstein
Wooldridge disclosed that she is on the
Consultant/Presenters’ Bureau for Astellas
Uroplasty.
Shanna Atnip and Katharine O’Dell had no
actual or potential conflicts of interest in
relation to this continuing nursing education
activity.
This learning activity was partially funded
by an unrestricted educational grant from
CooperSurgical, Inc.
138
Pelvic organ prolapse, pessary, pelvic floor, billing and coding.
Objectives:
1.
Describe the initiation and management of pessary services in a health
care practice.
2.
Discuss the plan for fitting and dispensing of pessaries in a health care
practice.
3.
Explain the billing and coding system for pessary reimbursement.
opment of a practice plan. For
example, pessary fitting may be
accomplished by either using
actual pessaries or using fitting
kits. Either way, it is common for
a new user to try at least two or
three pessaries before finding one
that is comfortable and effective
(Komesu et al., 2008). For this
reason, cleaning and sterilization
options for the chosen fitting
device must be readily available.
Providers are advised to check
with the manufacturer of pessaries they stock and follow the
recommended guidelines. In the
United States, many pessaries
and fitting kits are autoclavable
silicone, making access to an
autoclave an essential element of
the pessary business plan. However, for some air-filled pessaries,
such as the Donut and the inflatable silicone Donut, alternative
sterilization options should be
used (Bioteque of America, 2011).
When the decision has been
made to stock pessaries and/or
fitting kits, the practice must
decide which styles and sizes to
stock. In terms of their clinical
use, pessaries can generally be
divided into three categories:
support pessaries that are re-
Urologic Nursing Editorial Board Statements of Disclosure
In accordance with ANCC-COA governing rules Urologic Nursing Editorial Board statements of disclosure are published with each CNE offering. The statements of disclosure for
this offering are published below.
Susanne A. Quallich, ANP-BC, NP-C, CUNP, disclosed that she is on the Consultants’
Bureau for Coloplast.
All other Urologic Nursing Editorial Board members reported no actual or potential
conflict of interest in relation to this continuing nursing education activity.
UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3
Figure 1.
Sample Decision Tree for Pessary Practice Management
Will practice provide pessary care?
Know referral options
No
Yes
SPECIAL SERIES
Will care include fitting or only follow up?
Fitting and follow up
Limited pessary
stock
Purchase stock; plan
storage, inventory,
ordering methods
No special equipment if
site provides women’s
health services; know
referral options.
PESSARIES
Purchase at least
one kit from each
category. Check
local pharmacies/
medical equipment stores
related to options
for patient
purchase.
Complete
array of
pessaries
types and
sizes
ON
Fitting kits
only
Follow up only
Select and purchase
common sizes of at
least one type of
pessary from each
category. Know
referral options.
Complete equipment checklist (see Table 1)
tained by relatively intact pelvic
muscle integrity, support pessaries that are somewhat selfretaining, and pessaries that offer
additional urethral support for
women with stress urinary incontinence. Some large referral
practices may have sufficient
volume of potential pessary users
to justify stocking several styles
of each category of pessary, as
well as a complete range of sizes
of each style. Smaller practices
have several options for limiting
their up-front purchasing costs.
Table 1.
Office Resources Necessary for Pessary Management
Assorted pessaries and/or fitting rings
Pessary cleaning plan prior to re-sterilization
Autoclave, cold, or alternate sterilization
Appropriate educational materials
Follow-up visit tracking system
After-hours contact and referral plan
General pelvic examination equipment, including options for vaginitis and urinary tract infection screening
Pessary cart or other storage area
Inventory and re-order plan
UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3
139
SERIES
1.
Cidex OPA® is used to disinfect pessaries in the bladder control clinic.
2.
First, clean the pessaries with enzymatic detergent. Mix 15 mL of detergent
with 1 gallon of water. Soak pessaries for 5 minutes.
3.
Thoroughly clean and rinse the pessaries and pat dry.
4.
Test Cidex OPA with Cidex OPA test strips according to package directions
to make sure the solution meets minimum effective concentration, recording
date, time, lot number of solution, test pass or fail, and staff member initials
in the monitoring log.
5.
If the solution passes, proceed to disinfecting the pessaries. If it does not,
discard the solution, clean and dry the container, and put new solution in.
Test this new solution to make sure it passes and meets the minimum
effective concentration, recording results in the monitoring log.
6.
After donning the appropriate personal protective equipment (gloves,
goggles, and gown), place the pessaries in the Cidex OPA for 12 minutes for
high level disinfection.
7.
After 12 minutes of soaking, remove the pessaries from the Cidex OPA and
thoroughly rinse the pessaries with tap water. Dry and repackage the
pessaries with the date and size of the pessary.
SPECIAL SERIES
ON
PESSARIES
Figure 2.
Sample Office Procedure for Cold Sterilization of Pessaries
For example, sterilizable fitting
kits are now available for Ring,
Cube, Incontinence Dish, Oval,
and Gellhorn pessaries (Atnip &
O’Dell, 2012; Bioteque of America,
2011). Practice costs associated
with fitting kits include the original cost of the kit(s) and their
upkeep. Options for sterilization
after cleaning include autoclaving, with specifications dependent on the type of autoclave used,
or cold sterilization with a product, such as Cidex OPA® or
Chlorophenyl®, followed by
thorough rinsing with water
(Bioteque of America, 2001). An
example of a written procedure
for cold sterilization for office
use is presented in Figure 2.
If fitting kits are used, a prescription for the device is typically provided to the potential user,
who then obtains the device
through a pharmacy or medical
supply store. In some cases,
insurance may cover all or part of
the cost of the device. Cost comparison may demonstrate an economic advantage to the provider
when fitting kits are utilized.
However, practice decision-makers should also consider patient
satisfaction, including potential
140
aggravation of delays in symptom relief. This may be especially problematic for women who
require a subsequent change in
pessary type or size after a trial of
daily use.
If actual pessaries are stocked,
the number of types and sizes to
keep as inventory must be determined. In provider surveys, the
most commonly used pessary
styles are variations of the Ring
pessary (with and without a support membrane, and with and
without an incontinence knob),
and Gellhorn pessaries (Cundiff,
Weidner, Visco, Bump, &
Addison, 2000; Pott-Grinstein &
Newcomer, 2001). The most
common sizes of Ring pessary are
2 through 5 (whole numbers).
Gellhorn pessaries are sized by
the dish diameter in quarter-inch
increments, with common sizes
ranging from 1.75 to 3.0 inches
(CooperSurgical, 2011). When
ordering decisions are being
made, limiting pessary styles to
those with drainage holes may
offer an advantage by allowing
normal vaginal discharge to pass
from the vagina, rather than pooling as a potential culture medium. This may decrease infection
risk but has not been well studied.
When a decision is made to
limit the number of in-house
stock, unusual sizes can be specially ordered, or the patient can
be referred to specialty practice. If
a referral is made, users can be
offered the option of returning to
the original practice for follow-up
visits once a satisfactory pessary
is identified for on-going use.
Similarly, small practices may
choose to refer all potential users
for pessary fitting, with the
option of seeing established pessary users for follow-up care only.
Insurance reimbursement can
be expected to vary by region of
the country. In making a business
plan, providers should obtain
estimates of typical reimbursements for pessary-related visits
and supplies from established
local providers, from local professional organizations, or directly
from third-party payers. Comparing this information with
anticipated purchase and overhead costs can inform decisionmaking. While pessary practice
may not be lucrative, it should be
seen as an important component
to offering a breadth of women’s
health care services. Taking time
to carefully consider stocking,
sterilization, and referral options
should help maximize both user
and provider satisfaction in terms
of cost-effectiveness and time
management.
Supply, Equipment, and Procedural
Considerations for Pessary Practice
Several other practice-plan
components should be considered (see Table 1). In the absence
of established national standards,
pessary care can reasonably take
place in a variety of practice settings including urogynecology,
urology, general gynecology, and
primary care. However, rare complications can be life-threatening
(Atnip & O’Dell, 2012; O’Dell &
Atnip, 2012). Designated providers within any practice should
have demonstrated competence
UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3
SERIES
Figure 3.
Sample Patient Handout – Pessary Care Instructions
Why do I need a pessary?
A pessary is a silicone support device used to support the vagina in women
who have prolapse (dropping of the pelvic organs) or some kind of urine loss.
Pessaries come in many sizes, shapes, and variations. For example, some are
designed for self-removal, but some are not; some can be worn during sexual
intercourse; some will only stay in place if a woman still has strong vaginal
muscles. A pessary can be a comfortable, safe way for many women to control
pelvic problems for a short time or for years.
How often does a pessary need to be removed for cleaning?
This varies. Some women remove their pessary every night and put it back
in the next morning, others remove their pessary occasionally or to have sex,
while others only have their pessary removed at an office visit every few months.
The best plan for you depends on the type of pessary that works for you and what
you prefer. Even if you remove and clean your own pessary, you still need to be
seen regularly for follow-up care because pessaries can cause painless but
serious pressure sores in the vagina.
• To Insert: Wash your hands,
lubricate your vagina. Wash/dry your
hands again. Fold the pessary.
Insert.
• To remove: Wash your hands. Insert
one finger into your vagina. Hook
your finger through the finger hole,
loop, or above the top of the pessary,
and pull out and downwards.
What should I expect if I use a pessary?
While you use a pessary, you should be seen regularly to be sure the
pessary is not causing painless sores in your vagina. Between visits, call if you
notice any changes, especially pain, bleeding, increasing odor, or problems
passing your urine or bowels. At each visit, your pessary will be removed and
cleaned, your vagina will be examined for irritation, and if everything is okay, your
pessary will be reinserted. Here is our plan for your care.
[Insert your plan of care.]
Do I need any creams or treatments?
We may advise you to use a vaginal estrogen with your pessary. These
preparations can be an important way to prevent infection and injury because
they can increase blood supply and elasticity. This may also make pessary
removal and insertion more comfortable. Other treatments, such as a gel called
Trimosan®, can make the vagina more pH-balanced (acidic), and decrease risk
of odor or infection. DO NOT use petroleum jelly (Vaseline®) or other oil-based
lubricants with your pessary.
If you have problems or questions, please call us any time at [insert your
contact plan].
UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3
141
PESSARIES
Your pessary is called a ________________________________ pessary, size
___________.
ON
How do I care for my own pessary?
If you have a pessary, you can remove it easily and then replace yourself, or
we will work with you in the office to be sure you can:
• Remove your pessary.
• Wash it with warm water and soap.
• Rinse it well.
• Reinsert your pessary, often with a special cream we may prescribe.
SPECIAL SERIES
related to knowledge of comfortable and complete pelvic examination, normal and abnormal
pelvic anatomy and function, pessary indications and risks, and
management of complications.
Written material and educational diagrams related to pelvic
anatomy, pelvic floor dysfunctions, and specific pessary placement and care enhance patient
teaching and should be available
onsite and in take-home format.
Whenever possible, all material
should be available in languages
that meet the needs of women
seeking outpatient care. A sample
pessary handout is presented in
Figure 3. When women receive
both manufacturer and provider
care instructions, any discrepancies should be explained. Other
useful educational handouts
include summaries of related
treatment options, such as vaginal estrogens, anticholinergic
medications, urethral bulking
agents, and/or vaginal moisturizers and acidification products.
General equipment needed
to provide pessary care includes
many items already present in a
women’s health setting, such as
vaginal specula, proctology
swabs, straight catheters, lubricants, examination gloves, and
items for assessment of vaginal
discharge (such as pH paper,
microscopy, cultures) and urine
(such as containers and dipsticks). Cotton-tip applicators or
cytology brushes are useful for
cleaning pessary drainage holes.
Items specific to pessary care
include selected pessaries and/or
fitting kits, written information
and anatomic diagrams, items for
vaginal lavage (such as saline,
provodine iodine, 10 to 60 cc
syringe), and an autoclave or
alternate cleaning and sterilization plan. A small storage cart on
wheels may be useful for transporting equipment to various
examination rooms (see Figure
4). In addition, the office may
wish to stock other pessary-related items, such as tubes of acidifying gel (TrimosanTM).
SERIES
SPECIAL SERIES
ON
PESSARIES
Figure 4.
Pessary Storage Cart
Note: A pessary storage cart may facilitate transporting pessaries, supplies,
and educational materials to varied
examination rooms.
An important part of pessary
initiation is a trial of the pessary
as the woman performs a facsimile of her typical activities, such
as walking, sitting, climbing
stairs, bending, and sitting on a
toilet to urinate and defecate.
Including this type of trial period
at the office-fitting visit is likely
to preempt problems, such as urinary retention or return urgent
visits for pain or expulsion. The
trial period in the office area may
increase non-billable visit time,
and patient flow to facilitate
relaxed assessment should be
carefully considered before fitting appointments are scheduled.
Pessary complications are
more common when pessaries
are forgotten or neglected (Arias,
Ridgeway, & Barber, 2008). For
this reason, several safe guards
should be in place. First, a tracking system should be developed
to insure that women who miss
pessary return visits are quickly
contacted and rescheduled.
Some clinicians advise all women, and in particular, women
with memory impairment, to
wear medical alert bracelets,
identifying them as a pessary
user. Others require a new pes-
sary user to sign an informed
consent form acknowledging
understanding of pessary risks
and warning signs, and responsibilities during follow up. Additionally, if pessary providers are
not always available, pessary
users should be aware of a plan
of obtaining care at any hour in
cases of urgent or emergent problems.
Ordering Pessaries
Several companies distribute
pessaries in the U.S., and potential providers should check costs
of supplies and delivery to their
area. Table 2 lists a sample of distributors and their Internet-accessible services. Providers can access several other important services from pessary distributors or
their representatives, including
product fitting and care advice,
and assistance with purchasing
and reimbursement information
(Artisan Medical, 2011; Bioteque
of America, 2011; CooperSurgical,
2011; Personalmed, 2012). Pessary distribution may change
ownership, and providers will
need to reassess their purchasing
options intermittently.
Table 2.
Examples of Pessary Resources in the United States
Pessary-Related Products
Other Web-Based Services
Artisan Medical
Company
www.artisanmed.com
Web Site
Wide range of pessaries
Online ordering
Bioteque of America
www.bioteque.com
Bioteque pessaries; Fitting
kits for Ring, Oval, Cube,
Gellhorn, Incontinence Dish.
Pessary removers
Online ordering;
downloadable pessary
selection chart, patient
education brochure, product
information
Vaginal dilators
CooperSurgical
www.coopersurgical.com
Milex pessaries; Fitting kits
for Ring pessaries; Trimosan
acidifying gel
Online ordering;
downloadable documents,
including pessary material
information sheet and
Magnetic Resonance
Imaging recommendations
Personalmed
www.personalmed.com
EvaCare pessaries; vaginal
cones, electrical stimulation
units
Online ordering
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UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3
SERIES
Table 3.
Commonly Used Billing Codes
Billing and Coding for Pessary
Reimbursement
Type of Code
Current Procedural
Terminology (CPT)
Diagnostic Code
Description
Uterovaginal prolapse
complete
618.3
Uterovaginal prolapse
incomplete
618.2
Cystocele (anterior
compartment prolapse)
618.01
Stress urinary incontinence
625.6
Urinary retention
788.20
Unspecified non-inflammatory
disorder of the vagina
623.9
616.10
Vaginitis, postmenopausal
atrophic
627.3
Vaginal stenosis
623.2
Supplies
Evaluation and
Management (E&M)
PESSARIES
624.1
Vaginitis/vulvitis
unspecified
ON
Vulvar atrophy
Vaginal discharge
Procedure Codes
Code
SPECIAL SERIES
Standards and guidelines for
billing offer providers the opportunity to receive appropriate compensation and continue their work,
and they offer payers the security
of assuring that charges reflect
actual services provided. Many
private third-party payers follow
regulations developed by the
Centers for Medicare & Medicaid
Services (CMS). Information for
providers is available at the CMS
Web site (www.cms.gov), with specific educational material available
free of charge through the affiliated
Medicare Learning Network (MLN)
(www.cms.gov/MLNGenInfo). For
Medicare purposes, both physicians and advanced practice registered nurses are fee-for-service
billers. Providers should regularly
review changes in standards and
guidelines as they become available through the CMS Web site.
As part of the billing process,
providers designate codes to identify 1) either the complexity of the
visit or the time spent with the
patient, if that is unusual related to
the expected complexity of the
visit; 2) specific procedures performed during the visit; and 3)
diagnoses demonstrating at least
primary and possibly secondary
indications for the care provided
(CMS, 2011a). Table 3 lists some
common codes used for pessaryrelated billing. Typically, only one
service can be billed per office day.
In certain circumstances, when
separate services are provided on
the same day, or a patient receives
services from separate providers
on the same day, a coding
Modifier may be appropriate to
identify this exception (CMS,
2011b). Provider documentation
in the medical record justifying
coding selections is essential to
retrospective audit of appropriate
billing. Because the billing process
may not always be straightforward, professional organizations
often offer Web-based assistance to
help members, and in some cases,
non-members, understand regulations in a specific field. For exam-
623.5
Pessary fitting and insertion
057160
Vaginal irrigation
57150
Non-rubber pessary (silicone)
A4562
Pessary, rubber, any type
A4561
New patient to practice (no
visits in past 3 years), code
selection based on
complexity OR time.
99203 (Detailed OR
30 minutes)
Established patient, code
selection based on
complexity OR time.
99212 (Problemfocused OR 10
minutes)
99204
(Comprehensive OR
45 minutes)
99213 (Expanded
problem-focused OR
15 minutes)
99214 (Detailed OR
25 minutes)
Modifier Codes
Same day: Separate service
and procedure/same
provider
Modifier-25
Same day: Separate service/ Modifier-HO
different provider
ple, the American Congress of
Obstetricians and Gynecologists
(www.acog.org), the American
Urological Association (www.
auanet.org), and the American
Urogynecologic Society (www.
augs.org) offer this type of member
UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3
service. Professional development
related to billing and coding is also
often included at annual professional meetings, such as those
sponsored by the Society of
Urologic Nurses and Associates
(www.suna.org).
143
SERIES
Table 4.
Examples of Pessary Types and Sizes
Type
SPECIAL SERIES
Size
Variations Available
Available: 0 to 13, in whole
numbers (equal to 1 ¾ to 5
inches)
Common: 2 through 5
Ring with or without central
support membrane.
Ring with incontinence knob
with or without support
membrane.
Donut
Available: 2 to 3 ¾ inches, in ¼
inch increments
Common: 2 to 3
Inflatable
Donut
Available: 2, 2.25, 2.50, 2.75
inches
Silicone Inflato-Donut or latex
Inflato-Ball
Gellhorn
Sized by the dish diameter:
Available: 1 ½ to 3 ¾ inches, in
¼ inch increments.
Common: 1 ¾ to 3 inches
Long stem or short stem
Cube
Available: Sizes 0 to 7 (1 to 2
¼ inches)
Common: 1 to 4
Choose option with drainage
holes. Compressibility will vary
by manufacturer.
ON
PESSARIES
Ring
Figure 5 describes a case
example of billing and common
codes used during a hypothetical
patient’s pessary care. However,
the information in this article can
only serve as an introduction to
this complex topic. Regulations
change, and the ultimate responsibility for conforming to regulations rests with the provider.
Conclusion
Vaginal support pessaries are
an important treatment option
for women who report symptoms
related to loss of pelvic support.
Careful consideration of pessary
practice options combined with
knowledgeable billing practices
should allow providers in a variety of settings to offer pessary fitting and follow up as an essential, cost-effective component of
women’s pelvic health care.
Figure 5.
Case Example: Pessary Billing and Coding
Marcia is a 66-year-old woman seen for a routine bi-annual gynecology visit by a new provider who is an enrolled
Medicare supplier. The purpose of her original visit meets the
criteria for a preventive visit. During a comprehensive interview,
she reports feeling something new coming out of her vagina,
with increasing pelvic pressure in the afternoon and evening. A
comprehensive physical examination (PE) confirms incomplete
uterovaginal prolapse. Marcia is shown anatomical drawings to
help her understand what is happening, and her options for
care are reviewed. She decides to try a vaginal support pessary, (see Table 4) and is easily fitted with a Ring pessary. She
finds it very comfortable during a 20-minute pessary trial performing general activities, such as walking in the office hallway.
She verbalizes understanding of the importance of regular follow up, typical expectations related to wearing a pessary, and
warning signs that would indicate she should call her provider.
Marcia leaves with the pessary in place, written information
about pessary care, and an appointment to return in two weeks
for a review of her satisfaction with the pessary, examination for
pessary-related mechanical injury, and instruction related to
pessary self-removal and reinsertion.
The provider documents the findings of the history and
PE, reporting that during the 90-minute visit, 30 minutes were
spent completing the preventative history and PE; 25 minutes
involved face-to-face patient education related to pelvic prolapse and treatment options, and 15 minutes were spent fitting
the pessary. The remainder of the 90 minutes, while Marcia
tested the pessary by walking in the hall and going to the bathroom, was not face-to-face time with the provider, and that time
is not included in the coding documentation.
When preparing the bill for this visit, the provider includes
codes for a Preventive Visit for a new patient over the age of 65
(Code 099387), with related diagnostic codes, such as
Gynecologic Examination Routine (V72.31) with Cervical
Routine Pap (V76.2); a modifier for Separate Evaluation and
Management and Procedure, Same Day, Same Provider
144
(Modifier-25); a Procedure code for Pessary Fitting and
Insertion (057160); a Supply code for Pessary, Non-Rubber
(A4562), and the Current Procedural Terminology (CPT) diagnostic code for uterovaginal prolapse incomplete (618.2).
Marcia calls to ask some questions in the next two weeks.
Later, she forgets her appointment and has to be called to be
rescheduled. During that call, the rationale and importance of
regular follow up is re-addressed. The provider does not submit
a bill for the 25 minutes spent during these two phone interactions because they are not billable, face-to-face patient education.
When Marcia returns, she reports de novo stress incontinence, and the decision is made to change the pessary. These
symptoms and the refitting are documented, along with the
content and time spent for patient education. Because a refitting is required, a billing decision must be made based either
on procedure (such as a pessary fitting) or time spent (such as
using an appropriate Evaluation and Management code).
Pessary follow-up visits typically range between 15 to 25 minutes depending on patient status and complexity (099213 or
099214). In this case, the refitting was not complex, and the
provider decided not to reuse the pessary fitting procedural
code. She discarded the used, unsatisfactory pessary, billed for
the new pessary as a supply, and added the CPT code for
stress urinary incontinence (625.6) as a secondary code.
If Marcia later returns with a problem, additional secondary diagnostic coding would be added (vaginitis/vulvitis
[616.10], atrophic vaginitis [627.3], vaginal discharge [623.5],
postmenopausal bleeding [627.1], urine retention [788.20],
mechanical complication of genitourinary device [996.39], and
urinary tract infection [599.0]). Specific treatments clinically indicated by the new diagnosis would be included (irrigation of the
vagina [057150], endometrial biopsy [058100], insertion of nonindwelling bladder catheter [051701]), with supply codes if
appropriate. Procedures done at routine visits for additional
diagnoses would continue to be designated with a Modifier-25.
UROLOGIC NURSING / May-June 2012 / Volume 32 Number 3
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References
cy? American Journal of Obstetrics &
Gynecology, 198, 577.e1-577.e5. doi:
10.1016/j.ajog.2007.12.033
O’Dell, K., & Atnip, S. (2012). Pessary
care: Follow up and management of
complications. Urologic Nursing,
32(3), 126-137, 145.
Personalmed. (2012). Management with
Eva Care® flexible silicone pessaries.
Retrieved from http://www.personal
med.com/pessaries.php
Pott-Grinstein, E., & Newcomer, J.R.
(2001). Gynecologists’ patterns of
prescribing pessaries. Journal of
Reproductive Medicine, 46(3), 205208.
Additional Reading
American Congress of Obstetricians and
Gynecologists (ACOG). (2010).
Coding and billing for pessaries. Retrieved from http://www.acog.org/
About_ACOG/ACOG_Departments/
Coding_and_Nomenclature/Coding_
and_Billing_for_Pessaries
ON
(HCPCS) overview. Retrieved from
http://www.cms.gov/MedHCPCS
GenInfo
Centers for Medicaid and Medicare
Services (CMS). (2011b). National
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