Ob-Gyn Coding Alert

Bonus: Here’s the documentation you need for cyst removals.

Are you scratching your head when it comes to reporting removal/excision, aspiration, or drainage of ovarian cysts? You’re not alone.

Key: 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.

Break down each approach, and you’ll have the tools you need to get your claim right every time.

Tip 1: Check Out 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).

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 red flag: Coding for the cyst removal may be straightforward, but you need to make sure your documentation measures up for medical necessity. The American Congress of Obstetricians and Gynecologists (ACOG) has outlined the following steps to ensure proper documentation in support of removing an ovarian cyst. 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.

Tip 2: 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. 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 incision in the vaginal canal, you should report 58800 (Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); vaginal approach), but if the ob-gyn aspirates through an abdominal incision, use 58805 (… abdominal approach).

On the other hand, if he performs laparoscopic aspiration, report 49322 (Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple)), says Melanie Witt, RN, MA, an ob-gyn coding expert based in Guadalupita, N.M.

Guidance for ultrasounds: Your ob-gyn may need to use guidance when he must aspirate the cyst blindly through the skin or vaginal incision. That means if the ob-gyn uses ultrasound guidance to place the needle that he uses to aspirate the cyst through the vaginal approach, you’ll also likely get to report 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation).

Alternatively, you could bill 76998 (Ultrasonic guidance, intraoperative) instead of 76942 if the physician performs the actual aspiration under ultrasound guidance. Because either ultrasound procedure could represent accurate coding in this situation, you should note that 76998 has a higher relative value than 76942.

As with every ultrasound guidance procedure, the physician is being paid for his interpretation as well as the performance of the guidance procedure. Documentation must contain more than “procedure done under ultrasound guidance.” Ultrasound guidance procedures also require permanently recorded images of the site to be localized, as well as a documented description of the localization process, either separately or within the report of the procedure for which the guidance is utilized.

Keep in mind: You will not need to include modifier 50 (Bilateral procedure) if the ob-gyn aspirates cysts on both ovaries because the vaginal and abdominal approach codes include the nomenclature “unilateral or bilateral.”

Watch out: Although the laparoscopic code does not specifically mention this, Medicare rules will not allow you to use a bilateral modifier. In addition, no matter which approach the ob-gyn uses, you should report the procedure code only once, no matter how many cysts the ob-gyn aspirates, Witt says.