Revenue Cycle Insider

Removal of endometria guideline’s rationale remains to be seen.

With January 1 comes a variety of CPT^® 2025-related headaches your ob-gyn practice will have to deal with, including tumor/cyst excision additions as well as some guideline revisions and additions — some of which cast mystery as to their rationales.

Check out these top ob-gyn changes to prevent your claims from landing in limbo next year.

Examine These New Excision of Tumors or Cysts Code Options

CPT^® 2025 deletes codes 49203-49205, which were based on the size of the largest tumor/cyst. Instead, you will report a code according to the total size of all tumor/cysts removed that fit into the following definitions:

• 49186 (Excision or destruction, open, intra-abdominal (ie, peritoneal, mesenteric, retroperitoneal), primary or secondary tumor(s) or cyst(s), sum of the maximum length of tumor(s) or cyst(s); 5 cm or less)
• 49187 (… 5.1 to 10 cm)
• 49188 (… 10.1 to 20 cm)
• 49189 (… 20.1 to 30 cm)
• 49190 (… greater than 30 cm)

“These new codes will enable surgeons to more specifically report destruction or excision of intra-abdominal tumors based on sum of the maximum length of the tumor or cyst,” says Stephanie Stinchcomb Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime coder and consultant in Summerfield, Florida.

Strike Off These Other Deleted Codes

As of January 1, you will no longer have 58957 (Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed) as a possible option.

Instead, for “resection [tumor debulking] of recurrent ovarian, endometrial, tubal, or primary peritoneal gynecological malignancies, with omentectomy, if performed, without lymphadenectomy,” you should refer to codes 49186-49190, according to the parenthetical note listed before 58958 (Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed, with pelvic lymphadenectomy and limited para-aortic lymphadenectomy). This means that reporting 58957 after January 1 will result in a denial.

Also, you’ll want to strike two influenza codes off your list. They are:

• 90654 (Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for intradermal use)
• 90630 (Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use)

Instead of these codes, CPT^® 2025 directs you to see 90653, 90655-90658, 90660-90662, 90664, 90666-90668, 90672-90674, 90682, 90685-90689, 90694, and 90756.

Follow These New and Revised Guidelines

Codes aren’t the only areas tweaked by CPT^® 2025. The code set also takes aim at guidelines. If you don’t follow these specific instructions, your claims are likely to be denied. Check out the old notes, new notes, and revisions below:

Heads up: One of these new instructions above is to bill an open removal of an endometrioma using the unlisted code 58999 (Unlisted procedure, female genital system (nonobstetrical)).

“An endometrioma is a manifestation of endometriosis and is referred to as a chocolate cyst of the ovary. This happens when endometrial tissue forms on the ovary,” says Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico. “In reality, it can be any formation of endometriosis outside of the uterus that forms a mass. Usually, the treatment is a cystectomy when it is on the ovary.” 

“We will need to look at the CPT^® changes book to find out why they have decided to make this an unlisted procedure when done via an abdominal incision instead of recommending 58925 [Ovarian cystectomy, unilateral or bilateral],” Witt says. “Currently, you can report codes 49203-49205, but these are being deleted and the replacement codes do not mention endometrioma removal.”

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor