Ob-Gyn Coding Alert

Question: Patient had a history of uterine fibroids, status post hysterectomy with bilateral salpingectomy.

Pathology report states:

1. corpus luteum cysts

2. left and right pelvis masses as cellular leiomyoma.

Surgeon did laparoscopic bilateral oophorectomy and resected multiple masses, several approximately 5-7 cm from right side wall, left side wall, and larger lesions in the left side and in the mid pelvis.

Should I report 58545 or 58546?

AAPC Forum Subscriber

Answer: You should not report 58545 (Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas) or 58546 (Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g).

If the patient already had a hysterectomy (removal of uterus), she can’t possibly have intramural or surface myomas (fibroids) and can’t have a myomectomy. Here’s a good reference from the American College of Obstetricians and Gynecologists (ACOG) about fibroids: (URL: www.acog.org/womens-health/faqs/uterine-fibroids). This eliminates the possibility to use 58545/58546.

Code 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method) sounds much closer to what the ob-gyn did.

You should also report 58661 (Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)). While you won’t see a National Correct Coding Initiative (NCCI) edit, many insurances will want to bundle 58662 and 58661. The op note should clearly indicate the separate work of removing the masses vs removing the ovaries, so you can justify on appeal.

Alternately, you could consider 58661 with modifier 22 (Increased procedural service). Again, the op note should indicate the additional work of removing the masses.