Ob-Gyn Coding Alert

Question: A different ob-gyn group operated on a patient, performing a total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. The patient had multiple postoperative complaints, including pain, cramping and fever. She came to my physician for a second opinion, and ended up in the hospital with fever and pain. My ob-gyn performed a laparoscopy and opened the vaginal cuff laparoscopically as a precaution for possible cellulitis and complaint of dyspareunia. He discovered a   2-cm mass in an old abdominal incision line. He converted the procedure to a laparotomy and found an abscess when he opened the old incision. How should I report this?

Kansas Subscriber

Answer: From a diagnostic perspective, you should get more information from your physician before attempting to pick the correct CPT codes. Was the mass a tumor or a cyst, and was it removed? Or was the mass really an abscess? We also don't know if the physician drained the abscess during this session.
 
For the open procedure, then, you could choose from several coding possibilities, depending on the findings. You might pick 49020 (Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open) for the procedure's open part if the ob-gyn removed the mass as part of the new incision and drained the abscess.
 
Similarly, a payer may reimburse 49020 with 49200-51 (Excision or destruction, open, intra-abdominal or retroperitoneal tumors or cysts or endometriomas; multiple procedures) if the doctor excised the mass separately from the incisional line and drained the abscess. Both of these codes can be billed together, according to the National Correct Coding Initiative, version 9.2. The diagnosis codes will be the finding plus V64.4 (Laparoscopic surgical procedure converted to open procedure).
 
If you submit the claim to a private payer, you may also find additional reimbursement for laparoscopically opening the vaginal cuff by reporting 49329-59 (Unlisted laparoscopy procedure, abdomen, peritoneum and omentum; distinct procedural service). This procedure would be linked to 625.0 (Dyspareunia), but you can only code for cellulitis if the patient is confirmed to have it. 
 
If the carrier is Medicare or subscribes to Medicare's rules, however, you should report your open-procedure choice with modifier -22 (Unusual procedural services). You would append this modifier only to the highest-valued open-procedure code. In either case, be sure to submit the operative report and a letter explaining in lay terms the patient's condition and why it required the extra work.
 
You may be tempted to append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to the procedure(s) because another ob-gyn recently performed similar services for the patient, but don't. This modifier only applies to the original surgeon who is trying to bill for another procedure during the first surgery's global period.
 
In addition, be sure to report any E/M services your ob-gyn provides. Because the patient self-referred for a second opinion, you can use the confirmatory consultation codes (99271-99275), or you can use a new patient E/M code (99201-99205). You may want to stick with the E/M code if the ob-gyn didn't perform an exam but did do extensive review of her records and documented counseling time spent face-to-face with the patient. CMS assigns 3.21 relative value units (RVUs) to 99274, for example, but gives 3.59 RVUs for 99204, which is a difference of nearly $14, according to the Medicare Physician Fee Schedule, unadjusted for geographic location.
 
Finally, because your ob-gyn admitted the patient for fever and pain, be sure to report the admit (99221-99223). If the doctor decided to perform the surgery on the same date as the admission, add modifier -57 (Decision for surgery) to the admit code. If he decided the next day to perform the surgery, append modifier -57 to the subsequent hospital care code (99231-99233).

 - The answers for Reader Questions and You Be the Coder were provided by Melanie Witt, RN, CPC, MA, an ob-gyn coding expert based in Fredericksburg, Va.; and Harry L. Stuber, MD, an independent gynecologist based in Cookeville, Tenn.