Oncology & Hematology Coding Alert
Hysterectomy and Follow-Up Observation
Question: A physician performed a hysterectomy, and two to three weeks later the same patient began chemotherapy. The physician bills 99236 (Observation or inpatient hospital care) to report observation of chemotherapy, using diagnosis codes V58.1 (Chemotherapy) and 183.0 (Malignant neoplasm, ovary) to show medical necessity. Medicare denies 99236, claiming it is part of postoperative care. I have tried using modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) because it was part of a staged protocol, but it is still denied. How can I code this correctly? New York Subscriber Answer: A surgical procedure such as hysterectomy is designed as a package. Remember that the purpose of the observation is not for the hysterectomy or related care; it is for chemotherapy. The chemotherapy encounter should be used as the primary diagnosis, and the cancer diagnosis should be billed as secondary. Common cancer diagnoses requiring this surgical procedure include cervical cancer (180.x), ovarian cancer (183.x) or uterine cancer 182.x. Code 99236 (Observation or inpatient hospital care, requiring a comprehensive history, comprehensive examination and medical decision making of high complexity) may be appropriate for a patient admitted to the hospital for observation or as an inpatient, but no other E/M charges for related care can be billed for that date.
In the situation described, the gynecologist-oncologist performed the surgical procedure and provided the chemotherapy. The chemotherapy visit is not to be included in the global package for the surgical procedure because it is not typical postoperative care for a hysterectomy, but is an additional service provided for the diagnosis of cancer. The diagnosis for this visit is not the hysterectomy, but the cancer. Code V58.1 should be used as the primary diagnosis, and the appropriate cancer diagnosis should be secondary.
If the gynecologist/oncologist admits the patient to the hospital as an inpatient with admission or discharge on the same day or for observation, 99234-99236 should be used. When "observation status" is initiated in the course of an encounter all other related E/M services provided by the supervising physician on that date are considered part of the initial observation care.
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