Ob-Gyn Coding Alert

Ovarian cysts are a common gynecological problem, yet they remain a challenge when it comes to ICD-9-CM coding, especially when the physician does not indicate the type of cyst. This is due in part to the variety of ovarian cyststhere are more than 15 typesand the fact that one type of cyst might go by several different names. Others share the same code even though by definition they are very different from one another. Still others do not fit into any designated category, and get assigned a dump code for unspecified.

The most common forms of cysts that we encounter are serous, hemorrhagic and dermoid cysts, explains Philip Eskew, Jr., MD, medical director of Women and Infant Services at St. Vincent Hospital in Indianapolis, IN, and the past chairman for the Committee on Coding and Nomenclature, American College of Obstetricians and Gynecologists (ACOG). We also see a lot of endometrial or chocolate cysts.

When asked if correct identification and diagnosis of the cysts was a common problem, Eskew says, Many times we have to operate prior to diagnosis, because we cant tell from the ultrasound what type of cyst it is, and we cant tell whether the cyst is malignant or benign. The cystectomy reveals the type of cyst with which we are dealing.

In order to ease the process for coding of each type of cyst, we have provided a definition of the most common types of cysts, along with the proper diagnostic code for each.

Functional cysts

The most common ovarian cysts are called functional cysts, which result from a collection of fluid forming around an undeveloped egg. The fluid, called a follicle, is normally about the size of a pea. There are three types of functional cysts, and they are non-malignant:

1. All follicular cysts use diagnostic code 620.0, follicular cyst of ovary:

Follicular cyst occurs when the follicle does not shrink after release of the egg, and has soft, thin membrane walls that contain a clear fluid. All follicular cysts are non-malignant, but can cause severe pain when ruptured, which dissipates after a few days. There are several types of, or different names for follicular cysts:

Atretic follicular cyst, or cyst of the atretic follicle. An atretic follicle is one that degenerates before coming to maturity; great numbers of such atretic follicles occur in the ovary before puberty. In the sexually mature woman, several are formed each month and are generally not significant.

Graafian cyst, or cyst of the graafian follicle. A cyst of the graafian follicle or of the vesicular ovarian follicle, is one in which the egg attains its full size and is surrounded by an extracellular glycoprotein layer (zona pellucida) that separates it from a peripheral layer of follicular cells.

Hemorrhagic cyst is one containing blood or resulting from the encapsulation of a hematoma.

2. Corpus Luteum cysts use diagnostic code 620.1, corpus luteum cyst or hematoma:

Corpus luteum cysts result when bleeding occurs after an egg is released.

Reabsorbtion of the blood causes the cyst to form. These are less common than follicular cysts, but can cause more symptoms and problems because they are larger. Problems can include torsion, or twisting of the ovary, causing severe pain. A delayed period is often another result. If a corpus luteum cyst ruptures, it can cause bleeding and may require surgery.

3. The following functional cysts are coded as 620.2, other and unspecified ovarian cyst:

Theca luteum, or theca lutien cysts, are generally small and bilateral, and filled with a clear yellow (lutien) fluid. Symptoms are minimal, and may include pelvic pressure or aching, or symptoms of pregnancy.

Corpus albicans is a retrogressed corpus luteum characterized by increasing cicatrization (scarring) and shrinkage of the ciatrical zone with an amorphous, convoluted, completely hyalinized lutein zone surrounding the central plug of scar tissue.

Retention cyst, resulting in some obstruction to the excretory duct of a gland

Serous cyst, containing clear serous fluid, such as a hygroma.

4. Dermoid cysts use diagnostic code 220, benign neoplasm of ovary:

Dermoid cysts, also called dermoids or ovarian teratomas, are usually benign. They develop when an immature egg is retained within the egg sac (ovary). Dermoid cysts may occur at any age but the prime age of detection is in the childbearing years, and they can contain a variety of tissues including hair, teeth, bone, thyroid, etc. and sebaceous (oily) material, neural tissue and teeth.

Dermoid cysts can range in size from a centimeter (less than a half inch) up to 45 cm (about 17 inches) in diameter. These cysts can cause the ovary to twist (torsion) and imperil its blood supply. The larger the dermoid cyst, the greater the risk of rupture with spillage of the greasy contents which can create problems with adhesions, pain, etc. Although the large majority (about 98 percent ) of these tumors are benign, the remaining fraction (about 2 percent) become cancerous (malignant).

5. Endometrial or chocolate cysts use diagnostic code 617.1, endometriosis of ovary:

Endometrial cysts result from endometrial implantation outside the uterus, as in endometriosis. A common cyst associated with edometriosis is the Chocolate cyst of the ovary with intracavitary hemorrhage and formation of hematoma containing old brown blood; often seen with endometriosis of the ovary but occasionally with other types of cysts.

Documenting Removal

Coding for the removal of these cysts (ovarian cystectomy) is straightforward, but proper documentation should also be present in the record, explains Melanie Witt, RN, CPC, MA, program manager for the Department of Coding and Nomenclature at ACOG.

ACOG has outline the following steps to ensure proper documentation:

Note: these steps apply for the purposes of 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 6cm. 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.

The surgical code for the removal/excision of an ovarian cyst is 58925 (ovarian cystectomy, unilateral or bilateral). But for a laparoscopic removal, the code needs to be selected based on the extent of the procedure, and the coder is reminded that in CPT 2000, the laparoscopic codes were renumbered. When an ovarian cyst 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). This procedure would be reported as 56303 in 1999.

When the cyst is large and difficult to remove, the physician may have to remove part of the ovary at the same time. This would be reported using code 58661 (Laparoscopy, surgical with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]). In CPT 1999, this procedure was reported using code 56307.

Despite the renumbering of the laparoscopic codes, the rules are the same. Diagnostic laparoscopy is always an integral part of surgical laparoscopy and would not be reported separately