Ob-Gyn Coding Alert

Navigating the specialty of urogynecology can already present numerous challenges, but the complexity can increase significantly when a procedure spans multiple medical disciplines (such as general surgery, urology, or thoracic surgery). As a coder, it’s your job to figure out how to correctly code the different procedures detailed in the operative note for these cases.

In the upcoming clinical scenario, you’ll need to apply a range of knowledge, from coding principles to medical terminology, to accurately determine the answer. Once you’ve coded the scenario, see if your solution matches that of our expert.

Review This Procedure

Procedure notes: The patient underwent a laparoscopic robotic-assisted radical cystectomy, which involved the use of advanced robotic technology to remove the bladder laparoscopically for bladder cancer. The provider also performed a hysterectomy. This included the removal of the uterus, cervix, and upper part of the vagina through an incision in the abdomen. Additionally, the provider performed a bilateral salpingo-oophorectomy, which included the removal of both fallopian tubes and ovaries, along with a partial vaginal resection and a bilateral complete pelvic lymph node dissection with the removal of lymph nodes from both sides of the pelvis to check for the spread of cancer.

Explanation: When you first start trying to determine the appropriate code for a robotic-assisted radical cystectomy procedure, you might encounter some difficulties. The code 51570 (Cystectomy, complete; (separate procedure)) is typically used for a complete cystectomy, but it’s important to note that this code is only suitable for open procedures that involve bladder removal. In this case, where the provider performed a radical cystectomy on a patient, the removal of the uterus, ovaries, and a part of the vagina were also performed. These additional procedures will require additional coding.

Coder’s note: The operative report for a robotic-assisted cystectomy includes an initial incision, camera advancement, and robotic port placement before the procedure begins. For complete or radical robotic-assisted cystectomies, use unlisted code 51999 (Unlisted laparoscopy procedure, bladder) due to the laparoscopic approach. However, this code only represents the bladder component of the radical cystectomy, so you’ll need to report the remaining services separately.

Once you use an unlisted code to describe this portion of the service, you’ll need to find a suitable comparison code and determine a comparative percentage.

For example, a provider might find a laparoscopic complete cystectomy is 25 percent more work than the comparable open procedure code, 51570. But remember to account for the multiple services included in the radical cystectomy that you’re coding separately. This could lead to more reimbursement for 51999 than 51570, but this is based on payer reimbursement rules.

Remember: When submitting an unlisted code to the payer, you should not only submit the claim on paper, but also include the most appropriate comparison code in Box 19 of the CMS-1500 form. Stephanie Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime urology coding expert and consultant in Glen Burnie, Maryland, explains, “reporting an unlisted code will require manual review by the health plan and may delay processing of the claim.”

Avoid Errors While Coding Additional Procedures

Because you are coding the radical cystectomy using an unlisted bladder procedure code, you must also consider how to report the rest of the services. While your initial inclination may be to report codes for each service, you should first look for any combination codes for the following supplementary procedures:

• Radical abdominal hysterectomy
• Bilateral salpingo-oophorectomy
• Partial vaginal wall resection
• Bilateral pelvic lymph node dissection

Note 1: When using procedure codes that involve a salpingo-oophorectomy, you should make sure the code description includes the following: “with or without removal of tube(s), with or without removal of ovary(s).”

Note 2: In this clinical scenario, the term dissection is interchangeable with excision as far as bilateral pelvic lymph node dissection code choice is concerned. You can verify this within the body of the operative report by pinpointing the portion of the surgery that involves removal of lymphatic vessels and tissue using bipolar and/or monopolar cautery.

With this information, you can navigate through the CPT^® code options, where you will find a single, comprehensive code that appears to cover all the mentioned services such as 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)). But be very careful when choosing the CPT^® code.

Coding tip: You’ll see that 58200 includes a variety of services in addition to a total abdominal hysterectomy; however, this code does not include the removal of the upper third of the vagina nor the bilateral lymphadenectomy, so consider all the particular components of the surgical encounter documented in the operative report to understand why CPT^® code 58200 doesn’t align with the clinical encounter.

The elements of this particular surgical encounter include everything in the CPT^® descriptor for 58210 (Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s)). The descriptor for a radical hysterectomy includes the removal of the uterus, cervix, and the upper one-third of the vagina, as well as removal of the tubes and ovaries and bilateral lymph node removal.

Even though the surgeon’s operative report mentions a bilateral pelvic lymph node dissection, it’s important to understand that this dissection is more comprehensive than the “para-aortic and pelvic node sampling” described in code 58200. Additionally, it’s crucial to remember that code 58200 is for an open procedure, while the procedures in this case were conducted using laparoscopic and robotic methods.

Correct coding: On the surface, then, it appears that instead of 58200, code 58210 more accurately describes this clinical scenario. But the problem is that we do not know if the radical hysterectomy was performed via an open abdominal incision, or a laparoscope was used, given that the cystectomy was performed laparoscopically.

Here’s why: “The radical abdominal hysterectomy CPT^® code 58210 includes all the components included in the operative report such as the removal of the uterus, cervix, partial removal of the vagina, fallopian tubes, ovaries, and the total removal of the pelvic lymph nodes performed in an open procedure. However, the code 58548 [Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed] describes the same procedure but done via the laparoscope. It is important to verify the approach for all procedures before coding the service. The 51999 unlisted laparoscopy bladder code covers the laparoscopic robotic-assisted cystectomy,” says Storck.