Ob-Gyn Coding Alert

Question: Our physician performed an open abdominal myomectomy and removed 19 fibroids. He also performed an open paratubal cyst excision. I have researched and can only come up with 49203. However, the work involved in the myomectomy is far greater then the excision of the paratubal cyst based on his documentation in the operative report. Would I be correct to code 58140 for the myomectomy and 49203-52 for the excision of the parartubal cyst?

Illinois Subscriber

Answer: CPT^® added the code 49203 (Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less) to represent a very complicated removal of tumors, even thoughcysts are mentioned. Per the CPT^® Coding Changes book in 2008: "The intent of these new procedure codes (49203-49205) is to report an open procedure for the excision, ablation, or destruction of peritoneal tumors differentiated according to the size of the largest tumor removed during a single session. The old codes (49200 and 49201) were meant to report tumor debulking of the abdomen."

The vignette submitted to CPT^® when 49203 was added to the book is as follows: "A 27 year-old nulligravid female presents with progressive pelvic pain and dysmenorrhea. She desires future fertility. A pelvic ultrasound shows a 3cm right pelvic sidewall mass with morphology consistent with an endometrioma. A recent diagnostic laparoscopy showed extensive pelvic endometriosis with a 3 cm endometrioma on the right pelvic sidewall, distorting the course of the right ureter, and multiple implants in the pelvic cul-de-sac that was judged too complex for laparoscopic excision. The patient is scheduled for an open excision of intraperitoneal and extraperitoneal endometriomas."

Because of this and the high RVUs assigned to this code, you should not use 49203 (with 34.69 RVUs) to report the excision of a simple paratubal cyst.

If part of the tube was removed with the cyst, you might consider 58700 (Salpingectomy, complete or partial, unilateral or bilateral [separate procedure]). If not and this was an incidental finding at the time the fibroids were removed, you should not report it at all.

You could possibly add a modifier 22 (Increased procedural service) to the myomectomy code, but with 19 fibroids, you are already using the highest paying code 58146 (Myomectomy, excision of fibroid tumor[s] of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g, abdominal approach) with 32.79 RVUs. I doubt the documentation will support significant additional work involved.

Alternatively you could report 58999 (Unlisted procedure, female genital system [nonobstetrical]) and compare the work to 58925 (Ovarian cystectomy, unilateral or bilateral). If this had been done laparoscopically, you would have reported 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method) for the excision. There is simply no good black and white answer here.