Ob-Gyn Coding Alert

Although a limited number of codes exist to diagnose and bill for endometrial cancer surgeries, a careful reading of the operative reports and an itemization of what was done in the operating room can lead to optimal reimbursement. Knowing what items are bundled, and when they can be unbundled is another step toward billing for everything that is allowable in these advanced surgeries.

Treatment for endometrial cancer is usually a combination of radiation and surgery. Because of the limited number of CPT codes for endometrial surgeries, and the single ICD-9 code for cancers limited to the endometrium, coders often code for long, complicated surgeries with little supporting materials. A patient may have endometrial cancer (182.0, malignant neoplasm of body of uterus; corpus uteri, except isthmus [includes the cornu, fundus, endometrium and myometrium] or 182.1, malignant neoplasm of body of uterus; isthmus [lower segment of the uterus]) and have surgery to remove it.

The techniques for removing this cancer are very similar to those used to remove ovarian, tubal or primary peritoneal cancer. Yet the procedure codes for that type of cancer cannot be used without a diagnosis of ovarian, tubal or primary peritoneal cancer, and procedure codes specific to complicated endometrial cancer surgery are hard to come by. With non-ovarian/tubal cancers, coders need to find the CPT codes that are the closest approximation to what was done in the operating room, making sure that all of the procedures are linked to a justifying diagnosis. Melanie Witt, RN, CPC, MA, an ob/gyn coding expert and independent coding educator, offers a breakdown of the most common endometrial cancer surgeries and reveals some pitfalls of and solutions for comprehensive coding.

Coding Case Studies

The treatment chosen for endometrial or uterine cancer depends largely on how advanced the cancer is. Other factors include age of the patient, overall health and whether the patient wishes to have children. And while a combination of treatments surgery, radiation therapy, hormonal therapy and chemotherapy may be pursued, the ob/gyn surgeon or ob/gyn oncologist will primarily be involved in the surgical aspects of the patients care. Depending on the extent of the cancer, the following surgeries may be performed:

Hysterectomy: The basic procedure will be the removal of the uterus, tubes and ovaries. Most often this is accomplished abdominally and coded 58150 (total abdominal hysterectomy [corpus and cervix], with or
without removal of tubes[s], with or without removal of ovary[s]). The basic hysterectomy is performed when cancer has not spread outside the uterus and the cancer has not deeply invaded the uterine lining (stage-one cancer). This surgical approach is usually preferred because of better access to the peritoneal cavity for assessment, removal of the ovaries and the collection of washings. In some cases where the uterus is very small and the cancer is in its very early stage with minimal invasion, the surgery may be accomplished vaginally. In that case, use 58262 (vaginal hysterectomy; with removal of tube[s], and/or ovary[s]). Some surgeons prefer the laparoscopically assisted abdominal hysterectomy because it has the advantages of both an abdominal and vaginal procedure. The code in that case is 58550 (laparoscopy, surgical; with vaginal hysterectomy with or without removal of tube[s], with or without removal of ovary[s] [laparoscopic assisted vaginal hysterectomy]).

Peritoneal washings: An assessment of the peritoneal cavity for evidence of tumors or malignant areas would be done during the abdominal hysterectomy. The surgeon may also obtain peritoneal washings to send to the lab to determine if there is any hidden spread of cancer cells. This procedure does not have a CPT code and is included as part of the abdominal hysterectomy by most payers. If the procedure is done through the laparoscope, some coders may be tempted to bill for laparoscopic biopsy or aspiration (49321 or 49322). Code 49321 is for a biopsy, which means, in this case, the removal of tissue; therefore, it is not correct. While 49322 can be used for the aspiration of a cavity or cyst, it is generally considered an incidental procedure by many payers when performed with other laparoscopic procedures and therefore not paid separately. However, it does not mean that the coder cannot try to bill for it making sure of adequate documentation.

Lymph node sampling: Many times lymph node sampling will be done, especially when there are grade-two and -three tumors or when the tumor is deeply invasive. This involves taking samples from some of the pelvic and periaortic nodes. The code for this procedure is 38562 (limited lymphadenectomy for staging [separate procedure]; pelvic and para-aortic). Note that this code is a separate procedure code that may be bundled by the payer. As this procedure is not an integral part of an abdominal hysterectomy, it can be coded in addition to 58150, but it may be necessary to add modifier -59 (distinct procedure) to bypass any bundling edits. The payers usual fee reductions for second, third, etc., procedures apply to this modifier as well, so billing your full fee for the procedure is important.

When the lymph node sampling is performed via the laparoscope, use 38570 (laparoscopy, surgical; with retroperitoneal lymph node sampling [biopsy], single or multiple). Notice that this is not a separate procedure code and therefore only modifier -51 (multiple procedures) would be needed if required by the payer.

When the physician determines that a pelvic lymphadenectomy with sampling is required instead of the staging procedure, CPT provides codes that describe this procedure as part of the primary procedure (see below) unless a laparoscopically assisted vaginal hysterectomy (LAVH) was performed. The code for an open pelvic lymphadenectomy is 38770 (pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes [separate procedure]). The code for a laparoscopic pelvic lymphadenectomy with periaortic lymph node sampling is 38572.

Radical hysterectomy: This removes the uterus as well as the neighboring areas the parametrium and uterosacral ligaments and includes a partial vaginectomy. This operation is used when endometrial cancer has spread to the cervix or parametrium. The surgery to correct this problem may be 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]) or, more likely, 58210 (radical abdominal hysterectomy, with bilateral total pelvic lymphad-enectomy and para-aortic lymph node sampling, [biopsy], with or without removal of tube[s], with or without removal of ovary[s]).

Just as there are primary and secondary carcinomas to remove during these surgeries, there are primary and secondary diagnostic codes. Because the cancer originated in the uterus, the first diagnostic code is 182.8 (other specified sites of body of uterus). Since the cancer spread to the cervix, parametria and possibly part of the vagina, the secondary code is 198.82 (secondary malignant neoplasm of other unspecified sites; genital organs). This will be the secondary code for virtually all cancers that have spread from the uterus, but are still contained to the genital organs.

Omentectomy: When a patient is diagnosed with papillary serous adenocarcinoma, she is at increased risk for metastases of the cancer outside of the uterus and pelvis. For this reason, a partial omentectomy may also be performed. The code for omentectomy is 49255 (omentectomy, epiploectomy, resection of omentum [separate procedure]). Note that the code does not describe a partial omentectomy. For this reason, some payers may require the addition of modifier -52 (reduced services) for accuracy. If the omentectomy is bundled by the payer when the hysterectomy is performed, modifier -59 (distinct procedure) can also be added. Because you always want to list your payment modifiers first, modifier -59 would go first because it tells the payer to bypass the edit and pay the service. Modifier -52 is added second to explain that the full procedure was not performed. Remember to charge the full fee when the -52 modifier is indicated on the claim. This allows the payers computer to apply any payment reduction to your full fee, not a reduced fee.

There is no laparoscopic code for an omentectomy, partial or complete. When this procedure is necessary due to the type of cancer, a laparotomy incision will generally be performed to remove the omentum.

Coding Case Study

The following is a coding case study taken from an operative report:

Preoperative Diagnosis: Adenocarcinoma of the endometrium.

Postoperative Diagnosis: Same as above, however, greater than 50 percent myometrial invasion, pathology pending.

Operation Performed: Laparoscopic assisted transvaginal hysterectomy with bilateral salpingo-oophorectomy, laparotomy with pelvic and periaortic node dissection, partial omentectomy, pelvic washings.

Procedure: The patient was taken to the operating room and prepared in the usual manner for a laparoscopic procedure. Exam of the pelvic organs revealed an eight-week-size uterus without discrete ovary. The right and left ovaries appear to be within normal limits. There was no evidence of excrescences or signs of metastatic disease in the lower pelvis along the bowel or serosa, nor was there evidence of metastatic disease in the upper abdomen, liver and dome of the diaphragm. Dissection was then performed. The removal of the uterus was performed vaginally with the assistance of the laparoscope, and the pathologist was present to open the organ and render an opinion. There was an enlarged, fungating, relatively superficial lesion of the endometrium; however, up in the patients right fundal area there appeared to be invasion of the myometrium at least two-thirds of the way through. This dictated that a laparotomy and pelvic node dissection would be performed. The laparoscope was removed and a new incision was made to enter the peritoneum. Pelvic washings were obtained from the right cul-de-sac and pelvic area. A partial omentectomy was then performed with the aid of multiple Kelly clamps. The pelvic node dissection was performed, first on the right side identifying the ureter evenly. The dissection was carried down to include the internal and external iliac lymph nodes. This same procedure was performed on the left side, and dissection was also performed below the bifurcation of the aorta and tissue was obtained in the periaortic lymphatic chain area. The surgery was ended at this point, the peritoneum closed and the patient brought to the recovery room in stable condition.

Coding Options

Two surgical approaches were used during this surgery, laparoscopic and abdominal. The surgeon completed the LAVH (58550) and then converted to an open procedure for the remainder of the surgery. The open procedure involved a partial omentectomy (49255-59-52) and pelvic and periaortic lymph node dissection. Note that the term periaortic used by the surgeon is the same as the term para-aortic used in CPT. The coder needs to determine whether the physician performed lymphadenectomy (removal of all of the lymph nodes) or simply did pelvic and periaortic lymph node sampling.

While there is a code for pelvic lymphadenectomy, there is none for periaortic lymphadenectomy. Rather the existing codes describe a limited periaortic lymph node sampling (or lymphadenectomy). Therefore, the term dissection is not codeable in this scenario without additional information. However, it is likely that the physician has performed sampling due to the findings and protocol recommendations. In that instance, the correct code is 38562-59. If the physician had done a complete pelvic lymphadenectomy, the code changes to 38770-59.

Note that since the physician did not convert the hysterectomy to an open procedure, the LAVH should not be recoded as 58200. The diagnosis code for this case is 182.0 for all three procedures billed. It would not be necessary to indicate V64.4 (laparoscopic surgical procedure converted to open procedure) in this case because the laparoscopic procedure was completed before moving on to another approach for the other procedures.