Ob-Gyn Coding Alert

Coders who work in practices that treat gynecological oncology are familiar with the limitations of existing CPT Codes for cancer surgeries. There are too few codes, and they do not describe the variety of procedures currently in use to excise cancer, which makes it difficult to code for the services performed in the operating room. Additionally, due to the complex nature of cancer surgeries, coders often have difficulty determining which procedures are included or bundled into a code, and which can be coded and billed separately.

When it comes to gyn oncology coding, the question most often asked is, What is included? Coders need to know what they can and cant bill for per the available CPT surgical codes, says Melanie Witt, RN, CPC, MA, former program manager for the American College of Obstetricians and Gynecologists (ACOG) department of coding and nomenclature and an independent coding educator.

When codes are assigned to the operative reports for cancer surgeries, Katie McClure, RHIA, surgical coder at Southeastern Gynecologic Oncology, an outpatient surgery center with five physicians in Alpharetta, Ga., says that the reports often describe extensive debulking procedures in which the physician excises multiple tumors or performs several procedures in the same operative setting. I find that a good rule to go by is always to read the body of the operative report to determine exactly what was done. For example, our physicians perform retroperitoneal dissections often. The op report helps me determine what they actually did before I assign the code did they excise disease, or was it just an exploratory procedure?

A Problem of Too Few Codes

As surgical techniques for cancer removal advance, many complain that new codes are not being introduced quickly enough to keep up with the changes. Another problem is the lack of codes to describe any gynecological cancer other than ovarian malignancies. For instance, some women have endometrial cancer (182.0, malignant neoplasm of body of uterus; corpus uteri, except isthmus [includes endometrium]). The surgical techniques for removing this type of cancer are very similar to those used to remove ovarian cancer. Yet the ovarian cancer codes cannot be used (they would be rejected by the carrier without a diagnosis of ovarian cancer), and procedure codes specific to uterine (the endometrium is the lining of the uterus) cancer dont exist, Witt explains. Obviously, this makes coding for endometrial cancer or other uterine cancers a challenge. The only codes specific to genitourinary cancer are those for ovarian malignancy. With other cancers, coders need to find the CPT codes that are the closest approximation of what was done in the operating room, says Witt.

In billing with the existing codes for ovarian or uterine cancer, coders need to be aware of what services are bundled and what can be billed separately. In reviewing the surgical codes for gynecological malignancies, we have identified the most common extra services performed with each surgery, and indicated whether they are bundled.

Ovarian Oncology Procedures

Code 58943 (oophorectomy, partial or total, unilateral or bilateral; for ovarian malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingectomy[s], with or without omentectomy) includes several procedures with the surgery that cannot be billed separately. These include:

Inspection and evaluation of pelvis and abdomen
Diaphragmatic assessments
Excision of ovaries (one or both)
Salpingectomy, if performed
Omentectomy, if performed

Other procedures that may be performed but which would still be bundled with this major surgery are:

Limited lymphadenectomy, if performed
Exploratory laparotomy
Exploration of retroperitoneum

If a complete pelvic lymphadenectomy is performed, however, 38770 (pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes [separate procedure]) can be reported with a -59 modifier to indicate that it was a distinct procedural service. Some payers also may require that a -51 modifier be appended for multiple procedures.

Code 58950 (resection of ovarian malignancy with bilateral salpingo-oophorectomy and omentectomy) includes the following services with the surgery:

Inspection and evaluation of pelvis and abdomen
Excision of both ovaries and tubes
Omentectomy

If a hysterectomy were performed in addition to this resection, code 58951 (see below) would be reported instead. If both ovaries and tubes were not removed, this code would be reported with a -52 modifier to indicate reduced services.

Code 58951(resection of ovarian malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy) includes the following services in the surgery:

Inspection and evaluation of pelvis and abdomen
Excision of uterus
Excision of both ovaries and tubes
Omentectomy
Pelvic lymphadenectomy
Limited para-aortic lymphadenectomy

If a radical dissection is performed in addition to the resection, report 58952 (see below) instead of this code.

Code 58952 (resection of ovarian malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking) includes the following services in the surgery:

Inspection and evaluation of pelvis and abdomen
Excision of both ovaries and tubes
Omentectomy
Cytoreduction of tumor implants
Limited lymphadenectomy, if performed

If a hysterectomy is also performed at this surgical session, report 58150 (total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]) with a -51 modifier.

If a complete, rather than limited, pelvic lymphadenectomy is performed at the same time, report 38770 (pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes [separate procedure]) with modifier -59. Some payers may also require a -51 modifier.

Code 58960 (laparotomy, for staging or restaging of ovarian malignancy [second look], with or without omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diaphragmatic assessment with pelvic and limited para-aortic lymphadenectomy) includes:

Inspection and evaluation of pelvis and abdomen
Peritoneal washings
Omentectomy, if performed
Biopsy of abdominal and pelvic peritoneum
Diaphragmatic assessment
Pelvic lymphadenectomy
Limited para-aortic lymphadenectomy
Irrigation of peritoneal cavity

Genitourinary Malignancy Codes

The codes in this category are fewer and less specific as to what procedures are performed than the codes for ovarian oncology procedures. Witt advises coders to report the code closest to what was actually done, and append the appropriate modifiers.

Code 58200 (total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube[s], with or without removal of ovary[s]) includes the following in the surgery:

Inspection and evaluation of pelvis and abdomen
Excision of uterus
Removal of ovary(s) and/or tube(s), if performed
Partial vaginectomy, if performed
Para-aortic and pelvic lymph node sampling
Removal of tumors from uterus

A D&C (dilation and curettage, code 58120) is not included and can be reported separately, but medical necessity for the procedure must be documented on the claim. If a pelvic lymphadenectomy is performed in addition, report 58210 instead (see below).

Code 58210 (radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling [biopsy], with or without removal of tubes[s], with or without removal of ovary[s]) bundles the following procedures with this surgery:

Inspection and evaluation of pelvis and abdomen
Excision of uterus, cervix
Excision of upper 1/3 of vagina
Excision of tubes and ovaries, if performed
Para-aortic lymph node sampling
Bilateral pelvic lymphadenectomy

An omentectomy, if performed, can be reported separately using coding sequence 49255-59-51 (omentectomy, epiploectomy, resection of omentum [separate procedure]; distinct procedural service;
multiple procedures).

Code 58240(pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube[s], with or without removal of ovary[s], with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof) bundles the following in the surgery:

Inspection and evaluation of pelvis and abdomen
Excision of uterus, cervix and parametria (if present)
Excision of all or part of vagina
Excision of bladder and rectosigmoid
Construction of urinary conduit from intestine and ureters with reimplantation into neobladder
Creation of stoma neobladder
Creation of end sigmoid colostomy

If a neovagina is created during this procedure, the surgeon should report those codes that reflect the work performed. For instance, if the physician creates the neovagina without using a donor graft, code 57291-51 (construction of artificial vagina; without graft; multiple procedures) would be reported. If the physician uses a donor graft, the code 57292-51 (construction of artificial vagina; with graft; multiple procedures) would be reported instead. Code 57292 includes harvesting the graft, but does not include repairing the graft site (see 15734 (muscle, myocutaneous, or fasciocutaneous, flap; trunk). Should the physician perform either lymph node sampling or pelvic lymphadenectomy, the codes 38500-59 (biopsy or excision of lymph node[s]; superficial [separate procedure]), 38562-59 (limited lymphadenectomy for staging [separate procedure]; pelvic and para-aortic) or 38770-59 (pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes [separate procedure]) would also be reported. Once again, the -59 modifier is needed to show that these procedures were distinct from the rest of the surgery, and a -51 modifier might also be required to indicate multiple procedures.

Code 58825 (transposition, ovary[s]) bundles the following into the surgery:

Repositioning ovaries
Suturing them in place

Note that this procedure is performed prior to radiation therapy to protect the ovaries when they are not being removed. The procedure, when done during the same surgical session as other cancer surgery, would be reported by adding modifier -51. This code can be reported with any of the hysterectomy codes that do not stipulate mandatory removal of the tubes and ovaries as part of the procedure. Surgeons may choose to leave the ovaries in place if they are cancer free and the patient does not want to go into menopause prematurely.

Staged Procedures

Any of the above procedures could be scheduled as a staged procedure. That is, the physician first does a diagnostic procedure (e.g., 58120, dilation and curettage) followed by cancer surgery a few days later. In this case, add a modifier -58 (staged or related procedure or service by the same physician during the postoperative period) to the second procedure performed.

When it Is Not Cancer

Coders also should be careful in situations where cancer surgery is scheduled, but not verified by the pathology report. For instance, if the surgeon performs the procedure described by 59851, but the patient does not have ovarian cancer, the coder will need to report the individual procedures, i.e., 58150 (TAH), 38562-59 (limited lymphadenectomy) and 49255-59 (omentectomy) instead.

Follow-up to Surgery

When counseling a patient after surgery, about sexual function or chemotherapy, bill for an evaluation and management (E/M) visit with a -24 modifier (unrelated evaluation and management service by the same physician during a postoperative period). Witt also points out that a where to go from here discussion is not part of the global service and can be separately billed as an E/M visit with a -24 modifier.

For other follow-up to surgery visits that are covered under the global surgery period, code these as 99024 (postoperative follow-up visit, included in global service), along with the ICD 9 Code for surgery follow-up (V67.0, follow-up examination; following surgery). After the postoperative global period has expired (90 days on all surgeries discussed here), follow-up visits to check on the status of the cancer should be coded depending on whether cancer is still present. If present, code the cancer along with any symptoms the patient may be experiencing. If not present and the patient has no signs or symptoms, code in the following sequence: V71.1 (observation for suspected malignant neoplasm, not found); V10.40-V10.44 (personal history of malignant neoplasm; female genital organ); and V16.X (family history of malignant neoplasm), if applicable.

McClure agrees that V codes can be helpful in securing payment for both diagnostic surgery and follow-up care. Especially when a procedure has multiple CPT codes, use as many ICD-9 codes as you can to support the different procedures, and link them appropriately, says McClure. For example, if a colon resection is performed along with a hysterectomy, code the metastatic disease to the colon if this has been diagnosed, and attach it to the colon resection code for better chance of payment. McClure and Witt also recommend that coders use as specific a diagnosis code as possible. For example, if you use pelvic mass or unspecified endometriosis as the code to support a hysterectomy, you are taking your chances on it getting denied. I often have to wait for the final pathology diagnosis to tell me specifically what is wrong, but I have found this extra effort is worth it because claims will get paid first time around, says McClure.

McClure also warns that many insurers incorrectly bundle multiple surgical procedures. I appeal these, stating that Medicare and the Health Care Financing Administration consider these separately payable procedures. McClure sends copies of the explanation of benefits back to the insurers with the appeal. Coders are advised to include a copy of the appropriate pages from ACOGs Ob/Gyn Coding Manual: Components of Correct Procedural Coding for additional ammunition to getting claims paid.