Ob-Gyn Coding Alert

Surgeons who perform complex, multistage gynecological procedures typically spend several hours in the operating room and often make critical decisions as they operate. Between assistants at surgery, extra clinical staff, tests and x-rays run during surgery, a tremendous amount of overhead goes into these procedures. Therefore, correct coding is essential to obtaining the maximum reimbursement allowable for such surgeries. Yet multistage surgeries are replete with opportunities to undercode and miss out on critical payments. Proper coding of complicated surgeries means dissecting each stage of the surgery and determining which procedures are bundled with others, and which can be billed separately.

Debbie Vernon, patient account manager with Willowbend Womens Center, a four-physician practice with one nurse practitioner and three triage nurses in Plano, Texas, shares a recent example of a complex surgery her practice completed:

The patient presented with a diagnosis of papillary serous cystadenoma of the right ovary, a right hydrosalpinx with occlusions, a hemorrhagic cyst of the left ovary, periappendiceal adhesions with hemorrhage and endometrial polyps.

Vernons surgeon performed a laparotomy with a right salpingo-oophorectomy and appendectomy, and a left ovarian cystectomy. The surgeon also conducted an extensive lysis of adhesions including enterolysis, myomectomy, a right retroperitoneal dissection and ureterolysis, and a hysteroscopy with D&C (dilation and curettage). The surgeon employed an assistant surgeon during the operative session.

Code Step-by-step

When coding complicated surgeries such as the above example, the first step is to put the procedures in perspective to know if one or more of them may be a bundled procedure. The next step is to verify that all of the procedures are documented in the operative report and then make sure each of the procedures is justified by at least one of the diagnosis codes. Many payers will not reimburse for more than three procedures without either prior authorization or close scrutiny of the claim after the fact. That means submitting thorough documentation with the claim rather than afterwards to expedite payment.

Start by listing the surgical procedures based on the information provided to see what might be missing. Melanie Witt, RN, CPC, MA, an independent coding educator and ob/gyn coding expert, explains her approach to coding a complex surgery such as this. I generally like to use a coding table for the more complicated procedures, Witt says. It helps to quickly clarify what can be coded and in what order the procedures should be listed. Witts coding approach assumes that due to the extensive nature of the surgery, all procedures except for the hysteroscopy were performed through an abdominal incision. Witt has prioritized the procedures in the order they should be listed on the claim form. The prioritization is based on each procedures relative value units (RVU), as coders always want to start with the highest-paying procedure.

1. Procedure Description: Myomectomy, abdominal approach
CPT Code: 58140-59-22 (myomectomy, excision of fibroid tumor of uterus, single or multiple [separate procedure]; abdominal approach, -distinct procedural service, -unusual procedural services)
2001 RVU: 23.62
ICD-9 Code: No diagnostic information is listed to justify removing a fibroid. The physician must stipulate the type of fibroid, using one of the following: 218.0 (submucous leiomyoma of uterus), 218.1 (intramural leiomyoma of uterus) or 218.2 (subserous leiomyoma of uterus).
Comment: Code 58140 is a CPT separate procedure that is bundled with 58925 and 58740 per the Medicare Correct Coding Initiative (CCI). Add modifier -59 to get it paid. The -22 modifier is also added in case the lysis of adhesions was documented as extensive because lysis cannot be billed separately (see note below).

2. Procedure Description: Right salpingooophorectomy
CPT Code:58720-51 (salpingo-oophorectomy, complete or partial, unilateral or bilateral [separate procedure], -multiple procedures)
2001 RVU: 18.86
ICD-9 Code: 220 (benign neoplasm of ovary) and 614.1 (chronic salpingitis and oophoritis; hydrosalpinx)
Comment: This is a CPT separate procedure code but is not bundled with any of the gyn procedures done at this surgery, so modifier -59 is probably not necessary to indicate that a different surgery was performed on each ovary.

3. Procedure Description: Left ovarian cystectomy
CPT Code:58925-51 (ovarian cystectomy, unilateral or bilateral, -multiple procedures)
2001 RVU: 18.53
ICD-9 Code: 620.2 (other and unspecified ovarian cyst; hemorrhagic cyst)

4. Procedure Description: Hysteroscopy with D&C and polyp removal
CPT Code: 58558-51 (hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C, -multiple procedures)
2001 RVU: 7.30
ICD-9 Code: 621.0 (polyp of corpus uteri)

5. Procedure Description: Lysis of adhesions (assuming of the tubes and ovaries)
CPT Code: 58740 (lysis of adhesions [salpingolysis, ovariolysis])
2001 RVU: 10.94
ICD-9 Code: The information provided by Vernon did not list a diagnosis for adhesions. To have any chance of getting paid for lysis of adhesions of the ovaries/tubes, there must be a supporting diagnosis.
Comment: If the physician performed this procedure, it will be bundled into all three of the gyn abdominal procedures performed, per the CCI. To get paid for lysis of adhesions, documentation must clearly show extensive adhesions. Code the most extensive procedure (58140) with modifier -22 for a chance of payment.

6. Procedure Description: Enterolysis
CPT Code:44005 (enterolysis [freeing of intestinal adhesion] [separate procedure])
2001 RVU: 22.51
ICD-9 Code: As with lysis of adhesions, this procedure needs a supporting diagnosis.
Comment: This is a CPT separate procedure code that is usually bundled into any abdominal procedure. If extensive lysis was performed and documented, add modifier -22 to the code for the most extensive procedure performed by the surgeon who did the enterolysis.

7. Procedure Description: Right retroperitoneal dissection
CPT Code: 49200 (excision or destruction by any method of intra-abdominal or retroperitoneal tumors or cysts or endometriomas)
2001 RVU: 18.25
ICD-9 Code: There is no justifying diagnosis for this procedure.
Comment: Vernon needs to determine with her physician what the dissection involved. If performed to destroy retroperitoneal tumors, cysts or endometriomas, code 49200 would be the correct choice.

8. Procedure Description: Ureterolysis
CPT Code: Unknown with just this description
ICD-9 Code: There is no justifying diagnosis for this procedure.
Comment: Three codes in CPT describe ureterolysis, but to use them, the diagnostic criteria listed with the codes must be present; that is, the patient must either have retroperitoneal fibrosis, ovarian vein syndrome or retrocaval ureters. In most cases, the physician simply means he or she removed adhesions from the ureters and there is no CPT code for this simple procedure.

9. Procedure Description: Appendectomy
Code:44955 (appendectomy; when done for indicated purpose at time of other major procedure [not as separate procedure] [list separately in addition to code for primary procedure])
2001 RVU: 2.58
ICD-9 Code: 543.9 (other and unspecified diseases of appendix)
Comment: The primary surgeon for this procedure would list the code without a modifier because it is a CPT add-on procedure and would be the code of choice when the appendix is removed for a specific condition, like adhesions.

Vernon also mentioned that the practice did the assist on the surgery. Coding for an assistant is a fairly straightforward process because the assistant reports the same CPT codes as the primary surgeon with modifier -80 (assistant surgeon) added. Then the only question is whether the payer believes that an assistant was warranted for the procedures performed. If the patient is Medicare-eligible, however, and the surgery involves two primary surgeons, each performing his own surgical procedures, you may not bill the payer for cross-assisting. Under Medicare rules, a primary surgeon cannot also be paid as an assistant during the surgical session.

Coding is not an exact science, Witt concludes. But a careful assessment of what was done and what the diagnostic record shows is the surest place to start in a complex surgery. Ob/gyn coders need to ensure they have listed the CPT codes that are substantially correct and that each is supported by a justifying diagnosis.