General Surgery Coding Alert

Question: One of our surgeons performed a diagnostic laparoscopy with ovarian cystectomy. Would it be wrong to code as 58925 and 49320-51?

Florida Subscriber

Answer: Yes. If you were to bill 58925 (Ovarian cystectomy, unilateral or bilateral) and 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), you would not only be unbundling an existing procedure but also incorrectly specifying the surgical method.

If the cyst was removed laparoscopically, and the surgeon removed no part of the ovary with it (or any part of the fallopian tube), you should report 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method) for this procedure. If any part of the ovary/tube was removed with the cyst, you report 58661(... with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]).

Note that all procedures require exploration as part of expected and good surgical technique. The “diagnostic” part listed in the op report is integral to the entire laparoscopic approach, and you should never bill it separately.

More: Even if the surgeon performed a diagnostic laparoscope and an open removal, you should not separately bill for the diagnosis. That situation would change your code selection to describe an open procedure, but it doesn’t change the fact that the diagnostic lap is bundled.