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. Listing both procedures is called itemizing, but the catch is that you will need to have a diagnosis code for each procedure. It is conceivable that you could use the same diagnosis code (ie, 220) for both, but the payer may not consider that single diagnosis code as enough justification for reimbursing two procedures. A diagnosis of pain or mass might be suitable for the diagnostic procedure as it was performed first and was in response to the original complaints.

Tip: If the patient were a Medicare or CHAMPUS patient, only the most extensive procedure would be allowed, as these programs do not pay additionally for multiple approaches for the primary surgery.

The second choice is to code the laparoscopic removal of an ovarian cyst (56307 in this case due to the extent of the cyst), but add a modifier -22 (Unusual Procedural Services) to represent the additional work involved with the mini-laparotomy. This is the preferred method of coding according to the CPT book (page 203 of CPT 1999). In attaching the 22 modifier you would be asking for additional reimbursement. The amount by which you increase your fee will depend on your assessment of the additional work involved. There is no set amount for this increase.

Diagnosis codes:	

1.	220		3.  625.9
2.  	625.3		4.  789.34

Procedures:

Itemizing:                
58925 ovarian cystectomy   Dx 1
5630051 laparoscopy   Dx 3&4

Single Procedure:
5630722 partial oophorectomy   Dx 1

Medicare/CHAMPUS:              	
56307 partial oophorectomy   Dx 1

Terminology, Procedures and Codes Review This woman presented with dysmenorrhea (625.3). Dysmenorrhea is painful menstruation and occurs in more than 50% of all women (10% of whom will be incapacitated for 1-3 days each month). Absenteeism of young woman from school approaches 25%. The pain (625.9) and swelling (789.34) in the adnexa (the tissue surrounding the ovary and fallopian tubes) suggests the complaint may be the result of an ovarian cyst, also called a dermoid cyst or benign neoplasm of the ovary (220). Occurring during reproductive years, this common germ cell tumors contents resemble skin and can include hair, skin-like tissue, an oily sebaceous material and occasionally bone or toothlike material. The cysts are removed to avoid torsion and rupture, which can lead to peritonitis. While the physician was fairly confident he was dealing with a dermoid cyst, he could not confirm it until he was able to actually visualize the cyst during the laparoscopy. Laparoscopy (56300-56323) uses a fiberoptic instrument to visualize and evaluate the peritoneal cavity through a tiny incision in the umbilicus. CO2 or N2O is used to inflate the abdomen and allow the intestines to drop away from the abdominal wall (a pneumoperitoneum). Limited amounts of surgery can be performed using special tools through another tiny incision (the trocar incision). In this case, once the physician visualized the cyst, he decided that it was too large to remove via laparoscopy and opted for the mini-laparotomy. The laparotomy (49000) is an excision into the abdomen; the incision may be either vertical or horizontal. In this case, the physician does not need much room to work so he or she simply extends the trocar incision and then cuts vertically through the midline of the rectus muscles, which is referred to as Pfannenstiels incision. The ovary is lifted through the incision to make the cyst more easily accessible. Ovarian cysts are removed by shelling out the tumor from the normal ovarian tissue with the hope of causing as little damage as possible to the ovary. In this case the cyst is successfully removed and the ovary sutured and returned to the abdomen.

Article Contributors: Expert advice for this case study was provided by the following: Melanie Witt, RN, CPC, MA, program manager, department of coding and nomenclature, American College of Obstetricians and Gynecologists, Washington, DC; Evelyn M. Gross, CMM, CPC, NR-CMA, Healthcare Consultant-Accounting Firm Amper, Politziner & Mattia, New Jersey; Thomas Kent, CMM, Principal, Kent Medical Management, Dunkirk, MD; Dunnihoo, DR Fundamentals of Gynecology and Obstetrics. J.B. Lippincott and Co.: Philadelphia: 1990.