Ob-Gyn Coding Alert

Question: The physician performed a left salpingo-oophorectomy with drainage of right paratubal cyst and lysis of adhesions. Would the ASPIRATION of the paratubal cyst be included in the salpingo-oophorectomy (58661)?

Maryland Subscriber

Answer: No. You should report 58661 (Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]) with 49322 (Laparoscopy, surgical; with aspiration of cavity or cyst [e.g., ovarian cyst] [single or multiple]).

Remember, as per the latest Correct Coding Initiative (CCI) edits, code 49322 is a column 2 (component) code for more comprehensive procedure code 58661. Therefore, if you are billing for both procedures on the same claim and have documentation to back this up, you need to append modifier 59 (Distinct procedural services) to column 2 code 49322. This will let the payer know the ob-gyn performed the drainage of paratubal cyst on the right side and is separate from the left salpingo-oophorectomy. Some payers may require modifier LT (Left side) to be appended to 58661 to more clearly make your case.