Ob-Gyn Coding Alert

Bonus:  Here's the documentation you need for cyst removals

Coding for the removal/excision, aspiration or drainage of an ovarian cyst doesn't have to be rocket science. We-ve broken down each approach to give you all the tools you need to get your claim right every time.

Key concept: When you-re preparing to code for ovarian cyst removal, you should pay particular attention -to the approach, whether it is vaginal, abdominal (open) or laparoscopic,- says Laurice Trice, CPC, CCP, ob-gyn coding specialist at Cedars-Sinai Medical Center in Los Angeles. Cut Into These Ovarian Cyst Codes To -excise- an ovarian cyst means that the ob-gyn removes the cyst by cutting. If this is the case, you should use 58925 (Ovarian cystectomy, unilateral or bilateral), Trice says.

Heads up: For a laparoscopic removal of an ovarian cyst, however, you need to select the code based on the extent of the procedure.
 
For instance, when a laparoscopic ovarian cyst excision does not involve the removal of any additional ovarian tissue, the correct code for the procedure would be 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method).

When the cyst is large and difficult to remove, the ob-gyn may have to remove part of the ovary at the same time. You should report this using 58661 (Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]).

Documentation key: Coding for the cyst removal may be straightforward, but you need to make sure your documentation measures up for medical necessity. The American College of Obstetricians and Gynecologists (ACOG) has outlined the following steps to ensure proper documentation. Keep in mind that these steps apply for reporting an ovarian cystectomy for an asymptomatic benign ovarian cyst in a non-pregnant woman of reproductive age.

The following should be documented in the patient's medical record:

1. Last menstrual period and contraceptive method and one or more of the following:

a) Pelvic examination or ultrasound demonstrating a cystic mass that is 8 cm or larger

b) Persistence of a cystic mass of 6 cm or larger for two cycles

c) Presence of a cystic mass that is multilocular (many-celled) or has solid components, as confirmed by ultrasound.

2. Pelvic examination in the operating room or within 24 hours prior to the procedure to confirm persistence or presence of mass. Cyst Aspiration May Also Include US Guidance To -aspirate- an ovarian cyst means that the ob-gyn removes fluids by means of a suction device, but the terms -aspiration- and -drainage- are synonymous in this case. As the key concept listed above states, the code you choose will depend on the method the physician uses to perform the aspiration.
 
In other words, if the ob-gyn aspirates ovarian cysts through an [...]