Ob-Gyn Coding Alert

Question: Physician performed 49322, and in the process, he determined the cyst was a dermoid. The physician then proceeded to remove the dermoid cyst with monopolar cautery scissors. During same surgery, he also performed laparoscopic removal of endometriosis (58662) at sites that were separate and distinct from the dermoid cyst.

If the dermoid cyst was the only condition the physician treated, then 58662 would seem to be the best description for its treatment. However, that would essentially bundle the additional work performed for the dermoid cyst into the endometriosis removal, which is always billed as 58662. Should I consider 49322 (possibly with modifier 59, although CCI doesn’t bundle it with 58662) for the cyst treatment, then, since the op note documents the initial needle drainage, which was clearly additional work that is not typically a part of 58662? P.S. The op note does not document any removal of the actual ovary, so 58661 is not an option, either.

As an aside, I’m getting frustrated with the lack of CPT^® options for laparoscopic surgeries compared to open surgeries. This would easily be 49203 and 58925 if the procedures were open, but CPT^® normally includes laparoscopic ovarian cystec­tomies (not to mention ovarian wedge resections) into 58662. I hope CPT^® specifies laparoscopic surgical codes in a manner equivalent to open surgical codes in the future. Is there any way I can request such a clarification, and who would I send it to?

Codify Subscriber

Answer: The answer would be no. You cannot bill 49322 (Laparoscopy, surgical; with aspiration of cavity or cyst [e.g., ovarian cyst] [single or multiple]) for the aspiration of a cyst that was then removed. That falls into the same category as billing a biopsy for an organ you then remove; it is included.  

If he feels the aspiration added significant work and time to the surgical procedure due to the endometrial implants being fulgurated along with removing the cyst, you always have the option to add a modifier 22 (Increased procedural service).

An ovarian wedge resection represents partial removal of ovarian tissue. You should code this using 58661 (Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]), not 58662 (…with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method).

Code 58662 has higher relative value units (RVUs) to account for the fact that more work is required for the removal of endometrial implants plus tumors or cysts (as opposed to simply removing part of all of an ovary or tube).

Although it seems like a simple thing to simply add new codes, it is not. When new codes are added relative values from families of codes will shift which have a direct impact on reimbursement for other procedures. Plus, the process for getting a new code added can take up to 4 years even with good information.

If you want to pursue getting additional codes, you should contact the American Congress of Obstetricians and Gynecologists (ACOG) directly on this issue and present your case. It would be better if this contact comes directly from your physician. You are also free to fill out the required forms to request new codes from the AMA directly, but all requests will eventually go to ACOG for their support, so starting with ACOG is always the best strategy. You can learn about the requirements for requesting new codes at: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/applying-cpt^®-codes/request-form-instructions.page.