Ob-Gyn Coding Alert

Question: How should I code the following: diagnostic laparoscopy open, exploratory laparotomy, excision of left pelvic mass, and significant dissection of intra-abdominal adhesions? The diagnosis is complex left adnexal mass. Missouri Subscriber Answer: First, determine the CPT codes for each aspect of the procedure performed and then eliminate those that are bundled. In this case, you will be selecting from 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]), 49200 (Excision or destruction, open, intra-abdominal or retroperitoneal tumors or cysts or endometriomas) and 58740 (Lysis of adhesions [salpingolysis, ovariolysis]). According to the Correct Coding Initiative (CCI), when an ob-gyn performs any open abdominal procedure, he or she routinely performs an exploration of the surgical field to identify anatomic structures or any anomalies that may be present. Accordingly, you should not bill an exploratory laparotomy (49000) separately with any abdominal procedure. Consequently, you can eliminate 49000 from the list.

CPT labels diagnostic laparoscopy (49320) as a separate procedure. This indicates that Medicare generally bundles it into other procedures even though it can be performed separately, and you may not report the service when the physician performs a related, more comprehensive service. If this were a Medicare patient, it would eliminate 49320 from the list. If this is not a Medicare patient, you can bill the diagnostic procedure if you have a supporting diagnosis for doing it adding a modifier -59 (Distinct procedural service) to 49320. Or you can add modifier -22 (Unusual procedural services) to the converted abdominal procedure to indicate significant additional work. Some payers will reimburse for the laparoscopic procedure, and others will not. This leaves the excision of the pelvis mass (49200) and the lysis of adhesions (58740) as billable services. When you report multiple surgical procedures, you should bill the most expensive procedure first. In addition, you should append modifier -51 (Multiple procedures) to the lesser-valued procedure, in this case 58740. Medicare's CCI does not now bundle these two codes.