Oncology & Hematology Coding Alert

Gynecological oncologists can avoid the unbundling trap when assisting gynecologists with cancer-related procedures by learning how to properly code seemingly separate procedures as one, says Michael L. Berman, MD, FACOG, FACS, professor in the Department of Obstetrics and Gynecology at the University of California, Irvine. Berman also chairs the Coding Committee for the Society of Gynecological Oncologists. You can also use modifiers -62 (two surgeons) or -52 (reduced services) for the procedures, advises Barbara Levy, MD, FACOG, FACS, a private practitioner in Seattle, Wash. Levy serves on the coding and nomenclature committee of the American College of Obstetricians and Gynecologists (ACOG).

For example, a gynecologist may perform a hysterectomy while a gynecological oncologist completes the associated lymphadenectomy. To properly bill for the surgery, each physician would use the 58210 code (radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling [biopsy], with or without removal of tube[s], with or without removal of ovary[s]) with the -62 (two surgeons) modifier indicating that there were two surgeons involved, says Berman.

Berman says a classic example of erroneous unbundling would be for the gynecologist to use the 58180 (total abdominal hysterectomy [corpus and cervix], with or without removal of tubes[s], with or without removal of ovary[s]), while the gynecological oncologist uses 38770 (pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes [separate procedure]). You couldnt find a better example, says Berman in pointing to how the codes definitions clearly cover the two procedures.

Many gynecologists and gynecological oncologists are unaware that the unbundled coding is improper because theyve actually been paid that way. The payment may slip through, but with the Correct Coding Initiative (CCI) and higher sophistication among payers, the probability of an audit is more probable. Its incomprehensible that [carriers will] continue to pay for [unbundling] in the future, says Berman.

Unbundling also tends to occur in the gynecological oncology field because unlike other surgeons, gynecologists may not perform a full range of oncological procedures. Female genital system surgery codes (56405-58999) also group things that on the surface may be viewed as separate procedures, Berman explains.

The situation is even more complicated when a third surgeonusually assisting the gynecologistcomes into the picture. It would be incorrect billing, for example, for the two gynecologists to bill for the hysterectomy (58180), with the assistant using the -80 (assistant surgeon) or -81 (minimum assistant surgeon) modifier and the gynecological oncologist billing for the lymphadenectomy (38770), he says.

Berman says its only appropriate to code for two of the three physicians involved, leaving one without reimbursement. Theres no good solution. All three cant get paid. Typically its the assistant who gets short-changed, Berman adds.

The three-physician scenario may arise when the gynecologists, doing what they think is a routine hysterectomy, unexpectedly discover a carcinoma during the procedure. If the gynecological oncologist becomes the lead surgeon after getting into the case, however, then he would bill for his services using the surgical procedure code and the -52 (reduced services) modifier, indicating that he did not perform pre- and post-op care, says Levy. The surgical fee includes pre- and post-op care. If the oncological gynecologist is not doing those things, hes really coming in as a technician, she explains.

Using a single procedure code for many gynecological oncology procedures is appropriate but without the proper modifier, it wont be successful, Levy cautions. For example, if one uses -62 and the other doesnt, then whoever submits the bill first [to the carrier] will get paid, and the other wont, she explains.