Ob-Gyn Coding Alert

Question: My ob-gyn performed ablation of endometriotic lesion, diagnostic laparoscopy, lysis of adhesions, ovarian cystostomy, and left ovarian biopsy. She does not want me to bundle these procedures, but there is little documentation to support the adhesiolysis. How should I code these multiple procedures?

Texas subscriber

Answer: Unbundling procedures that CPT, the National Correct Coding Initiative (NCCI) or your carriers consider included in other procedures is not an option your physician can choose. Consequently, let's break down the services she provided.

The diagnostic laparoscopy (49320, Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) would be included once the physician performed any surgery through the scope. In fact, CPT states, "Surgical laparoscopy always includes diagnostic laparoscopy."

For lysis of adhesions, a carrier will only reimburse for adhesiolysis when the adhesions are dense, vascular, anatomy-distorting or took significant time and work to remove.

The surgeon must document this information in his operative note. In this case, your physician's documentation lacks the necessary supporting information, so the payer will likely deny 58740 (Lysis of adhesions [salpingolysis, ovariolysis]), even on appeal.

The ob-gyn performed a fulguration of the endometrial implants and cyst aspiration with biopsy as the main procedure. You should code these procedures as 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method), 49321 (Laparoscopy, surgical; with biopsy [single or multiple]) and 49322 (... with aspiration of cavity or cyst [e.g., ovarian cyst] [single or multiple]).

If you then examine NCCI for bundling edits, you will find that it does not bundle these codes. So report them in this order: 58662, 49322-51 and 49321-51. Use modifier -51 (Multiple procedures) to show the payer that the ob-gyn performed multiple procedures during one operative session.