Ob-Gyn Coding Alert

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 [...]