Oncology & Hematology Coding Alert

Question: Our physician diagnosed and treated a patient for ovarian cancer. Her tumor markers were normal for 10 months after chemotherapy, but then her CA-125 level started to rise. A CT scan showed a 3- to      4-cm tumor mass at the vaginal apex. The doctor performed an exploratory laparotomy, excision of omental tumor nodule, and extensive enterolysis. The report doesn't say that he removed the tumor. Can I report this with 58960 with modifier 22 (Unusual procedural services) for the extensive enterolysis?

Colorado Subscriber

Answer: Careful: Physicians perform second-look laparotomies on asymptomatic patients after surgery and/or chemo - not on patients with raised CA-125 and a tumor mass. For your scenario, report the enterolysis and surgery, rather than a second look.
 
Best bet: Check the op note. If the primary procedure is lysis, report 44005 (Enterolysis [freeing of intestinal adhesion] [separate procedure]), or if the physician used a laparoscopic approach, report 44200 (Laparoscopy, surgical; enterolysis [freeing of intestinal adhesion] [separate procedure]). Often the nodule removal is primary - take a close look at the procedure he describes. You may be able to report 49255 (Omentectomy, epiploectomy, resection of omentum), an unlisted-procedure code, or another code depending on the documentation.
 
58960 tip: Next time you consider reporting 58960 (Laparotomy, for staging or restaging of ovarian, tubal or primary peritoneal malignancy [second look], with or without omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diaphragmatic assessment with pelvic and limited para-aortic lymphadenectomy), be sure you've met the specific requirements of the code.
 
Many coders wonder if the "with or without" applies to the peritoneal washing and the other listed procedures. Many physicians perform all of the services with everything but the omentectomy, but according to CPT coding conventions, the technical definition is with or without each of the following: omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diaphragmatic assessment with pelvic and limited para-aortic lymphadenectomy.
 
Note: Extensive adhesiolysis is common with  "second-look" procedures - don't report this separately.