Ob-Gyn Coding Alert

OPERATIVE NOTE - Intraoperative Consultation
PREOPERATIVE DIAGNOSES: Paraovarian cyst
POSTOPERATIVE DIAGNOSES: Same as above
NAME OF PROCEDURE: Cystectomy with excision and removal of the cyst in toto
FINDINGS: Large approximately 10 cm paraovarian cyst of the right ovary. The right fallopian tube was tortuous and stretched over the full length of the paraovarian cyst, it appeared grossly distorted with multiple areas of pressure atrophy; Normal uterus; Normal right ovary with small cyst; Normal left fallopian tube and ovary.
COMPLICATIONS: None
DRAINS: Foley catheter
SPECIMENS: Right paraovarian cyst wall; cyst fluid sent for cytology
DVT PROPHYLAXIS: SCDs in place and the onset of the case
INDICATIONS FOR PROCEDURE: Female with acute appendicitis who was undergoing appendectomy when she was found to have a large right paraovarian cyst.
DESCRIPTION OF PROCEDURE: The patient was under general anesthesia and had undergone appendectomy when I was consulted regarding a large right paraovarian cyst. Informed consent for the removal of the paraovarian cyst was obtained from the patient’s mother.

Before starting my procedure, I noted that 3 trocars had been placed into the left mid-to-lower quadrant of the patient’s abdomen as follows; a 5mm umbilical port, a 5mm port in the suprapubic region and a 12mm port in the LLQ. The large paraovarian cyst was grasped using the laparoscopic grasper, then using the LigaSure with a blunt tip, the paraovarian cyst was excised from the right ovary. There was no spillage of the cyst contents during excision. The right ureter was noted to be peristalsing normally before and after excision of the paraovarian cyst. Excellent hemostasis was noted.

Dr. then assisted me by aspirating the cyst using a laparo­scopic needle until it was almost completely drained and then placing the cyst wall in an endopouch, followed by removal via the 12 mm port. The cyst was filled with approximately 200 mL clear, watery fluid that will be sent for cytology.

What should I report? Upon researching, this may apply to an unlisted CPT^® code 51999 or possibly CPT^® code 51555. Any input is appreciated.

Texas Subscriber

Answer: First, a lesson in medical terminology. “Cystectomy” is a medical term for surgical removal of all or part of the urinary bladder. Some physicians refer to the removal of a cyst as a “cystectomy,” but this is not the usual medical definition for this term.

Since the 51xxx codes in CPT^® represent urinary bladder procedures and this op note refers to a paraovarian cyst (paraovarian mean a cyst that is near the ovary or fallopian tube), the codes you suggest could not be reported.

According to the op note, the surgery was already under way when your surgeon came in to remove the cyst, and that the original surgery was being performed via a laparoscope. So the code to search for is laparoscopic removal of a cyst.

The op note first states that it was excised, and after excision and before it was removed via the scope, it was drained. This does not impact coding, as you code the most extensive part of the procedure only, which is the excision. That should lead you to code 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method).

However, he did not open or close the procedure and so may only take credit for the intraoperative part of the surgery. You must add a modifier 52 (Reduced services) to 58662 to account for this.