Ob-Gyn Coding Alert

Editors Note: This case is courtesy of Bonnie Lewis of Twin Falls, ID. Ob-Gyn Coding Alert is always looking for interesting cases for our expert coders to consider for our Case Study section.

Clinical Scenario

A sixteen-year-old female presents with severe dysmenorrhea and left lower quadrant pain. She has had the pain for several months, using numerous medications for pain control without much relief. There is no history of pregnancy and no significant family medical history related to the current problem. Upon examination the physician finds the abdomen to be soft, flat and non-tender, but the left adnexa is slightly tender and appears to be enlarged.

Concerned about the continuing dysmenorrhea and the apparent enlargement of the adnexa, the physician orders an ultrasound which reveals an enlarged left ovary with a solid mass 3x3x3 centimeters in size. The mass appears to be consistent with a dermoid cyst and the physician proposes a diagnostic laparoscopy, with the probable laparoscopic excision of the cyst and possible mini-laparotomy. After a discussion with the patients parents about the surgery and the possibility of complicating factors such as malignancy, the patient is scheduled for surgery.

The operative report states that during the laparoscopy the left ovary was visualized and found to have a large dermoid cyst. The cyst was dense and distended. It seemed to occupy the majority of the ovary and was determined to be too large to manage through the laparoscope. A decision was made to proceed with a mini-laparotomy. The pneumoperitoneum was partially released, instruments removed, umbilical incision closed and the trocar incision extended in a Pfannenstiel approach. The ovary was elevated through the incision into the operative field and an oophorocystectomy was performed. The ovary was checked and no excrescence was found on the outside. It was closed, returned to the cavity and the abdomen was closed with no complications.

Coders Note Book

The coding question that immediately comes to mind for this surgery is whether or not you should code for both the laparoscopy and the open removal of the cyst or just one of these procedures. You will not bill for a laparotomy in this case because a surgical procedure was performed through the laparotomy incision. Here you have two choices. One is, you can list the ovarian cyst removal (58952) first, then the diagnostic laparoscopy (56300) along with the -51 modifier. The -51 modifier indicates it was a multiple procedure. Although a diagnostic laparoscopy is also a CPT separate procedure (defined by CPT as a procedure that is normally an integral part of a larger procedure), a modifier -59 could not be used because this does not represent a distinct procedure, but rather is another approach to the same one. [...]