Oncology & Hematology Coding Alert

When CPT added surgical codes to permit gyn oncologists to report two common combinations when operating on ovarian and related cancers, confusion reigned among coders and physicians.

The additions help oncologists obtain accurate reimbursement for cancer surgeries that had lacked uniquely descriptive codes. However, the bundled edits, which arrived hard on the heels of the new codes, have kept everyone on their toes.

Nevertheless, "I think these are really good codes," says Melanie Witt, RN, CPC, MA, an independent coding consultant and educator based in Fredericksburg, Va., because until 2002, no code dealt with both abdominal hysterectomy and radical dissection.

New Codes Pay for Real Work

The original code 58950 (Resection of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy) was paired with two indented procedures 58951 (... with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy) and 58952 (... with radical dissection for debulking) that were used separately to address total hysterectomy and lymphadenectomy, and radical dissection.

The proper codes now follow under the heading Ovary, Excision in the CPT book CPT book:

For example, a patient with advanced-stage uterine cancer undergoes a hysterectomy, and during the same operating session the surgeon takes out the ovaries and tubes, removes the omentum and does some radical dissection for debulking. As written, code 58953 can and probably should be used, say Michael Berman, MD, FACOG, FACS, SGO liaison to the ACOG committee on coding and nomenclature and professor of obstetrics and gynecology at the University of California, Irvine.

The American College of Obstetrics and Gynecology (ACOG) requested these specific codes because frequently the physician was doing both procedures and reporting 58950 with 58951 or 58952, but "they were getting rejected because a lot of payers interpreted CPT such that the top code included the indented ones below it," Witt says.

With the present codes, the physician work in ovarian cancer surgery which is usually more involved than a simple removal of the uterus, Witt says can be properl reimbursed. RVUs for these codes are high but justifiable because these procedures are also serious surgery. For example, 58953 and 58954 carry RVUs of 50.79 and 55.21 respectively, while 58951 and 58952 are valued at 36.39 and 40.50.

Remember, Witt says, if you report one of these two codes, you never report the old codes as well. CPT has expanded not replaced the original codes because they were insufficient to describe all of the work done by the physician.

CCI 8.3 Punctures the Balloon

The October 8.3 CCI edits have created a new quandary for physicians, Berman says: "We're facing an issue where 58150 (Total abdominal hysterectomy ...) is bundled in with all the ovarian cancer section codes." For example, if one does a TAH BSO omentectomy, there is no longer any way to get paid for all three components of the procedure. "We used to use the 58950 code for BSO omentectomy with the 58150 code for the hysterectomy."

Now, Berman says, the only option is to use one of the other codes that includes a hysterectomy (typically the 58953 because it includes a description of radical dissection for debulking) and code it using modifier -52 for reduced services. "We have no way of knowing how that's going to work, but it's not a good situation because one is coding for a service that's substantially more than what the code would indicate." Berman expects that ACOG will develop another code for TAH BSO and omentectomy.

Regarding the other edits, Witt says, there's nothing to get in a twist about. She says that with 58953, 49010 (Exploration, retroperitoneal area ...) can be overridden with modifier -59 (Distinct procedural service). In fact, the bundles make some sense because the surgery itself is not in the retroperitoneal area, and if a cancer case requires exploration of that area you simply append modifier -59.

Some of the other codes that can never be billed with 58953 include exploratory laparotomy and the removal of tumors, cysts and endometrioma, which would logically be included in the radical dissection. "Those all have zeros, and I have no problem with that," Witt says. The latest edits have also added new codes to 58954: 38770 and 38780 both carry a 0 indicator. "These are lymphadenectomy codes, and they makes perfect sense because the new code includes lymphadenectomy," Witt says.

Ovarian Surgery Code Bundles

58953: 49010 can be overridden with modifier -59. Codes 44005, 44200, 44820, 49000, 49200, 49201, 57410, 58100, 58120, 58150, 58180, 58558, 58740, 58805, 58822, 58900 and 58925 cannot be overridden.

58954: 38570, 49010 can be overridden with modifier -59. Codes 44005, 44200, 44820, 49000, 49200, 49201, 57410, 58100, 58120, 58150, 58180, 58558, 58740, 58805, 58822, 58900 and 58925 cannot be overridden.

Dodge the Diagnoses Doldrums

Don't lose sight of the fact that 58953 and 58954 do not specifically delineate ovarian, tubal or primary peritoneal malignancy, Berman reminds oncology coders. He says that CPT "inadvertently left off the designation of the various cancer diagnoses for which these codes were meant to be used, and that has created some confusion."

Although "we have not included endometrial cancer for this family of codes because it's designed for a class of cancers that tend to behave in the same way," the codes may be used with an endometrial cancer that spreads intra-abdominally. Berman's final counsel is that "the codes are not restrictive, and it's up to the individual clinician to make an informed decision."

Witt also agrees that unless the code specifically delineates where the cancer is, if the code describes the procedure you do, you should be able to use that code.