Ob-Gyn Coding Alert

Question: Our ob-gyn did an exploratory laparotomy with removal of left ovarian mass. Can I code the removal as a separate procedure, or do payers consider this bundled?

Texas Subscriber

Answer: You should always bundle the exploratory laparotomy (49000, Exploratory-laparotomy, exploratory celiotomy with or without-biopsy[s] [separate procedure])-with an abdominal procedure.

You bill for the removal of the mass.-But you would have to refer to your op note and the pathology report. Did he take out only the mass, or did he remove the ovary and the mass?- If the former, you are looking at 49203-49205 (Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors -).

Note: You have to know the size of the mass to choose the appropriate code.

If the latter (and the mass was not a cyst), you code an oophorectomy (58940, Oophorectomy, partial or total, unilateral or bilateral). If the mass turned out to be a cyst instead of a tumor, you report 58925 (Ovarian cystectomy, unilateral or bilateral).