Ob-Gyn Coding Alert

Question: We billed CPT^® codes 58552 and 49322-59 because of additional documentation from the provider. Blue Cross Blue Shield (BCBS) only paid on the 49322 procedure and denied 58552 with the reason “charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.” Can you offer any advice on the best way to handle the appeal for this?

North Carolina Subscriber

Answer: This is a weird denial message given that they denied 58552 (Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)) in total.

Why did you also bill 49322 (Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple))? Code 58552 is a very comprehensive code, which includes the removal of the tubes/ovaries.

The National Correct Coding Initiative (NCCI) bundles 49322 into 58552, but a modifier is permitted to bypass the edit if you can meet the criteria. If you reported this code for the aspiration of an ovarian cyst, you probably will not be able to support the use of modifier 59 (Distinct procedural service); but if this was considered a bundling issue by the payer, they should have paid the 58552 and simply denied the 49322 (the lower paying code). Did you list 49322 as the primary code? If that is the case, they paid per their protocol.