Ob-Gyn Coding Alert

Case Description

A 30-year-old female, para 0, with a preoperative diagnosis of right ovarian dermoid cyst, is admitted for a laparoscopic ovarian cystectomy. Previously, after complaining of generalized pelvic pain, the patient had undergone a CT scan that showed a right ovarian cyst, possibly a dermoid cyst. Smaller cysts also were found on the left ovary.

Operative Report

The laparoscopic view of the pelvis demonstrated bilateral ovarian cysts. The largest, about 4-5 cm in diameter, was on the right side. A luteal cyst was also present in the right ovary. On the left ovary, a corpus luteum or follicular cyst was present in addition to another dermoid cyst.

Through three ports, various instruments were used to remove the ovarian cysts, as follows: Attention was directed to the right ovary. The capsule of the ovary was incised with a Corson needle passed through the suction irrigation tip. The capsule was then grasped with grasping forceps and peeled back, exposing the cyst, which was peeled out of the ovary. This was carried out on the right side without much difficulty, and after removal from the ovary, the cyst was placed in a plastic catch bag and brought out through the left lower quadrant port. The ovary was then inspected for bleeding and some small venous bleeding was cauterized with the Corson needle.

Attention was then directed to the left ovary and the cyst that appeared to be follicular was ruptured with the Corson needle and clear fluid drained. The other cyst was approximately 2-3 cm in diameter. It was opened with a Corson needle and found to be a dermoid cyst. The suction tip device was introduced in the cyst cavity and it was ultimately emptied and irrigated until clear fluid was obtained. The ovary was then opened further and the cyst contents and the cyst were peeled out of the ovary. Where the cyst wall appeared to still be adhered, it was cauterized with the Corson needle.

The operative summary lists the postoperative diagnoses as bilateral ovarian dermoid cysts and pelvic endometriosis.

Coding Dilemma

CPT guidelines say that when a procedure is performed through a scope, it should not be coded using an open code. This is because the surgical technique is different, requiring a different level of physician work and much less postoperative care. The AMA coding staff instead indicates that a laparoscopic code should be used to report the service even when a CPT code exists that describes the open procedure.

Yet the laparoscopic code range (56300-56344) does not contain a code that specifically describes an ovarian cystectomy performed laparoscopically. But because CPT instructs coders to report the most substantially correct code, one of the following two codes may be suitable to report:

56303 (laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method). In this procedure, fulguration or excision can be used to remove lesions on the ovaries and/or endometrial implants. Some coders may argue that a lesion, which is defined as any discontinuity of tissue, is not the same thing as a cyst, which is defined as a fluid-filled sac. But,our experts tell us, this level of specificity is not required in order to report code 56303 regardless of whether the lesion is tissue or fluid unless the cyst is drained rather than removed.

56307 (laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]). In this procedure, part or all of the ovaries and fallopian tubes are removed. The removal of a cyst that requires excision of part of an ovary in the process can be reported using this code as well.

The next issue is whether this code warrants a bilateral modifier (-50) to report removing cysts on both the right and left side.

And finally, we need to ask what diagnostic codes should be reported to justify the procedures and whether there are any other procedures performed that also could be reported.

Coding Solution

The most appropriate coding solution is to use 56303 for the excision of the dermoid cysts. In the above case study, only the two cysts on the ovary were removed and one was aspirated. Therefore, 56307 would not be appropriate to use.

The code 56303 does not usually take a bilateral modifier because of the operative area it describes. If the physician had documented significant additional work during the procedure, there might be a possibility of adding a modifier -22 (unusual procedure) to the code 56303, but in this case, the operative report did not support the use of this modifier.

Notice that the operative report included draining some additional cysts. The physician did not list this procedure in the operative summary, apparently because he thought the work was incidental to the primary procedure. This omission opens up the issue, however, of whether, with more documentation, code 56306 (laparoscopic aspiration) might have also been reported. The diagnostic coding could also be interesting. A dermoid cyst of the ovary is reported with ICD-9 code 220 (benign neoplasm of ovary). It is a three-digit code and should not be reported with additional digits (e.g., 220.0). The physician reported a small corpus luteum or follicular cyst in the left ovary, which was drained. A corpus luteum cyst and follicular cyst, however, are reported using different codes. ICD-9 code 620.0 describes a follicular cyst, while 620.1 describes a corpus luteum cyst. If the physician has decided to charge for the drainage of the non-dermoid cyst, the coder would have to clarify with the physician the correct type of cyst. The physician also noted pelvic endometriosis as a preoperative diagnosis. But because endometrial implants (ICD-9 code 617.1 for endometriosis of the ovary) were not cauterized and this diagnosis does not justify or support the removal of ovarian cysts, it should not be coded.

Therefore, coding should be as follows:

1. 56303 linked to ICD-9 code 220
2. 56306-51 (if documentedlinked to ICD-9
code 620.0)

Note: You cannot bill for 56300 (diagnostic laparoscopy) in addition to other laparoscopic codes because it is always considered included in a surgical laparoscopy.