Ob-Gyn Coding Alert

Question: My ob-gyn documented the following op note: “Omental adhesions made visualization of the pelvis difficult. These were covering the fundus of the uterus and anterior parietal peritoneal surface. Also, they completely obliterated the cul-de-sac. I found chronic and acute pelvic inflammatory disease as well as pelvic abscesses. Due to the large amount of adhesions, I spent a lot of time visualizing and freeing the fundus of the uterus, left adnexa, left tube and ovary, right adnexa structures, right tube and ovary, posterior cul-de-sac, and the sigmoid bowel. I lysed loops of bowel, and I removed the appendix. I exposed additional adhesions of the sigmoid bowel to the right cul-de-sac and lower pelvis as well as a large abscess, right of the sigmoid bowel. I placed a Jackson-Pratt drain to drain the pelvis.”

What CPT® codes are correct? Should I use modifier 22 on the laparoscopic appendectomy, or is the lysis of adhesions the more appropriate code with incidental appendectomy? What is the procedure for the J-P drain placement?

Colorado Subscriber

Answer: To answer your question, you need to resolve several issues. First, by your question, let’s assume the ob-gyn performed the entire surgery via a laparoscope. If the ob-gyn had done this procedure abdominally, your code choices would be different.

That said, you have only two codes for laparoscopic lysis of adhesions: 44180 (Laparoscopy, surgical, enterolysis [freeing of intestinal adhesion] [separate procedure]) and 58660 (Laparoscopy, surgical; with lysis of adhesions [salpingolysis, ovariolysis] [separate procedure]). Notice both are CPT® “separate procedures,” which means the payer is probably going to bundle either one into any other surgical procedure performed through the scope, like an appendectomy. Payers also bundle 44180 into 58660, so you cannot report both. If you are going to bill only for the lysis, you will have to choose which code represents more surgical work. Given the above brief description, you choice would likely be 58660.

Next, you need to determine if you should report the appendectomy at all. To do this, you will need to know if an appendectomy was the initial reason for the surgery or whether the ob-gyn removed an otherwise healthy appendix as part of the lysis. If the latter, you would report only the lysis; if the former, you would have to report the laparoscopic appendectomy (44970, Laparoscopy, surgical, appendectomy) and append modifier 22 (Increased procedural services) on that code to represent the additional work for the lysis. Payers permanently bundle 58660 and 44180 into 44970.

Finally, you should normally consider placement of drains and catheters as an integral part of a procedure. The exception would be placement of a suprapubic catheter, because it involves significant physician work, and of course has its own CPT® code (51102, Aspiration of bladder; with insertion of suprapubic catheter).