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Ob-Gyn Coding Alert

Coding Case Study:

Ovarian Surgery, Cancer Present or Not

Published on Tue Dec 01, 1998

Editors Note: The following case was developed by various members of OCAs Editorial Advisory Board in response to several reader questions about coding for potential ovarian cancer.

Clinical Situation

A 40-year-old mother of two children, presents with vague abdominal pain and an occasional sensation that she describes as abdominal fullness. She is menstruating normally, and has no other symptoms. The physician performs a pelvic examination and finds a unilateral palpable adnexal mass. Presence of a tumor is confirmed with transvaginal ultrasound, and a preoperative diagnosis is made indicating an ovarian tumor with low malignant potential.

The patient is scheduled for a recheck in six weeks, and the mass remains. The patient indicates her desire to remove the mass, as well as her intention to have no more children. The surgical evaluation identifies torsion of a 7 cm ovarian neoplasm. The tumor is removed during a total abdominal hysterectomy with right salpingo-oophorectomy. A second surgeon performed an omentectomy, a left pelvic para-aortic lymph node sampling, an appendectomy and a resection of the infundibulopelvic nodule on the infundibulo-pelvic ligament. Postoperative diagnosis remained the same: benign ovarian tumor.

Terminology and Procedures

Although it is not unrealistic to consider every ovarian neoplasm as potentially malignant, only about 20 percent actually fall into this category. ACOG suggests that the distinction between the two types can be made in most cases with a thorough history, physical examination and vaginal probe ultrasonography. Nevertheless, when the mass fails to regress within six weeks in a premenopausal patient, exploratory surgery is frequently performed.

In the above case, the first physician performed a total abdominal hysterectomy with right salpingo-oophorectomy. A total hysterectomy includes removal of both the uterus and cervix. A right salpingo-oophorectomy indicates removal of the fallopian tube and the ovary on the right (affected) side. The unaffected ovary was not removed in an effort to avoid the symptoms of the sudden onset of menopause. If cancer had been detected, a bilateral salpingo-oophorectomy would have been indicated.

The second physician performed an omentectomy, which is the removal of the omentum or extension of the abdominal lining that surrounds the uterus. This physician also did a left pelvic para-aortic lymph node sampling to remove sufficient tissue to check for any cancerous cells in the lymph node. Both of these procedures are typically performed when the patient has stage I malignant ovarian lesions, but in this case was done to rule out ovarian malignancy.

Finally, the surgeon removed the appendix (appendectomy) and a nodule on the infundibulopelvic ligament, which supports the fallopian tube as it leads away from the ovary.

Coders Notebook

1. Coding the Benign Tumor

In this case, the coding must reflect the fact that it turned out the patient did not have cancer. Of course, in order to make this diagnosis definitively, the ob/gyn office must wait for the pathology report. Once that report shows no presence of malignant cells, the postoperative diagnosis of benign ovarian tumor is recorded.

With this diagnosis, it would be correct for each physician to bill separately, as there is no CPT code that describes the procedures performed by both surgeons when cancer is not present. Correct coding would be as follows:

For the first physician, who performed the hysterectomy and removal of the affected ovary and fallopian tube, use the code 58150 for total abdominal hysterectomy (corpus and cervix) with or without removal of tubes, with or without removal of ovaries. This procedure is supported by the diagnosis code 220, benign neoplasm of ovary.

The second surgeon should bill separately for what she did, using 49255 for the omentectomy and 38562 for a limited lymphadenectomy for staging for the sampling of the lymph nodes. Both require a -59 modifier to identify the procedures as distinct from each other as both are CPT separate procedure codes. Alternatively, a coder could modify the lymphadenectomy code 38562 with a -22 modifier to indicate that the service performed was greater than that usually covered by that code in accounting for the omentectomy.

CPT seems to imply that the second surgeon also has the option to code a 58960 for staging of an ovarian malignancy, since the CPT includes in this code two of the procedures that this physician did (omentectomy and limited para-aortic lymphadenectomy). However, 58960 is clearly linked to malignancy (the RVUs are 30.58 compared to 17.45 for 49255 and 18.57 for 38562), and would not be supported by the postoperative diagnosis.

Neither diagnosis supports the appendectomy nor the removal of the infundibulopelvic nodule; therefore, these procedures should not get coded at all. The removal of the nodule appears to be a minor procedure because the body of the operative report stated that the nodule was located near the stump of the infundibulopelvic ligament. It was almost an incidental finding, and the nodule could have been removed at the time of the hysterectomy as part of that procedure.

2. What if the tumor was malignant?

Interestingly, if the diagnosis had been different, the coding would also have changed. Most notably, if the patient had been diagnosed with ovarian malignancy (183.X), both surgeons would bill together using 58951-62, excision with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy, modified for two surgeons. The reason for this is that the 58951 specifically cites ovarian malignancy in the nomenclature and includes an omentectomy, as well as the hysterectomy and lymphadenectomy.

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