Pathology/Lab Coding Alert

Finding the correct procedure code and diagnosis code for ovarian cysts can be a challenge. This is due in part to the large variety of ovarian cysts, and the fact that one type of cyst might go by several different names. Others share the same ICD-9 code even though by definition they are very different from one another. Still other ovarian cysts do not fit into any designated category, and get assigned to an unspecified ICD-9 code. The procedure coding for the pathologists examination of cystic ovaries depends on whether the condition is considered neoplastic. pathology Coder should understand the difference between cysts and know how to translate the definitions into the correct codes for proper reimbursement.

We assign both the procedure and the diagnosis code for ovarian cysts based on the pathology report, says Peggy Slagle, CPC, billing compliance coordinator for the department of pathology and microbiology at the University of Nebraska Medical Center in Omaha. Coders need to be familiar with the language they may see in the report describing the various cysts. And they must be educated about how to accurately translate that language into the correct ICD-9 code.

In our practice, the pathologist conducting the examination of the ovarian cyst assigns the procedure code, says Stephen Yurco III, MD, partner and pathologist at Clinical Pathology Associates in Austin, Texas. The examination will fall under one of two CPT codes: 88305 or 88307. Code 88305 (level IV surgical pathology, gross and microscopic examination) is used to describe the work involved in examining a cystic ovary from an oophorectomy (... ovary with or without tube, non-neoplastic), or an ovarian cyst from a cystectomy (... ovary, biopsy/wedge resection).

Code 88307 (level IV surgical pathology, gross and microscopic examination, ovary with or without tube, neoplastic) would be used for the examination of a neoplastic oophorectomy specimen, Yurco advises. Correct procedure coding clearly depends on the pathologists categorization of the cyst as neoplastic or non-neoplastic. Although the ICD-9 code is assigned by the clinician who receives our pathology report, we must use our pathological diagnosis to assign the appropriate procedure code.

Below are the definitions of the most common types of cysts, along with the proper ICD9 Code for each. It is also indicated whether the cyst is considered neoplastic and the appropriate procedure code to use based on that determination.

Functional Cysts

The most common ovarian cysts are called functional cysts. They are non-neoplastic, therefore you should code 88305 for the pathologists service for the examination of the ovary. Functional cysts are generally formed by the collection of fluid in the tissues of the egg-producing sac before, during or after ovulation.

During normal ovulation, an egg matures and is released from a sac called the follicle. Once the egg is released, the follicle briefly fills with blood, then changes into a yellowish shell called the corpus luteum, which produces progesterone. The corpus luteum eventually retrogresses, becoming a small scar body called the corpus albicans. Functional cysts may arise at any point in this process, and are categorized by that genesis. Below are the different names and ICD-9 codes used to describe the four main types of functional cysts:

1. Follicular cysts. Use diagnostic code 620.0 (follicular cyst of ovary)

Atretic follicular cyst, or cyst of the atretic follicle. An atretic follicle is one that degenerates before coming to maturity, and never releases the egg. Great numbers of such atretic follicles occur in the ovary before puberty. In the sexually mature woman, several are formed each month and are generally not significant. However, sometimes the atretic follicle fails to dissipate, and instead develops a buildup of fluid, forming a cyst.

Follicular cyst, or cyst of the graafian follicle. The follicle is also called the vesicular ovarian follicle. In this type of cyst, the egg attains its full size and is surrounded by an extracellular glycoprotein layer (zona pellucida) that separates it from a peripheral layer of follicular cells.

2. Corpus luteum cysts. Use diagnostic code 620.1 (corpus luteum cyst or hematoma)

Corpus luteum cysts result when bleeding occurs after an egg is released, and the blood is not successfully reabsorbed. These are less common than follicular cysts, but can cause more symptoms and problems because they are larger. Problems can include torsion, or twisting of the ovary, causing severe pain. A delayed period is often another result. If a corpus luteum cyst ruptures, it can cause bleeding and may require surgery.

Hemorrhagic cyst is another type of corpus luteum cyst involving the encapsulation of a hematoma.

3. Other functional cysts. Code as 620.2 (other and unspecified ovarian cyst)

Theca luteum, or theca lutien cysts, generally occur in both ovaries at once, and are small cysts, filled with a clear yellow fluid (lutien). They are the least common of the functional cysts, and are often associated with an abnormal pregnancy.

Corpus albicans cysts form surrounding a retrogressed corpus luteum. It is a cyst surrounding a central plug of scar tissue.

Retention cyst is a functional cyst that results in some obstruction to the excretory duct of the ovary.

4. Polycystic ovaries. Use code 256.4 (polycystic ovaries or Stein-Leventhal syndrome)
This diagnosis describes a build up of follicular cysts, typically in both ovaries, causing them to thicken and enlarge. They are often associated with menstrual problems and hormone imbalances, and the cause of fertility problems.

Dermoid Cysts

Code 88307 for the pathological examination of dermoid cysts, and use diagnostic code 220 (benign neoplasm of ovary)

Dermoid cysts, also called dermoids, ovarian teratomas or monster cysts, are usually benign. They develop when an immature egg is retained within the ovary and begins to develop without fertilization. Dermoid cysts may occur at any age, but the prime age of detection is in the childbearing years. They can contain a variety of tissues including hair, teeth, bone, sebaceous material, neural tissue, etc.

Dermoid cysts can range in size from a centimeter up to 45 cm in diameter. They can cause the ovary to twist (torsion) and imperil its blood supply. The larger the dermoid cyst, the greater the risk of rupture. Although about 98 percent of these tumors are benign, the remaining fraction can become cancerous.

Cystadenoma Cysts

For the pathological examination of cystadenoma cysts, use 88307 because they are neoplastic, and use 220 (benign neoplasm of ovary) for the diagnosis code.

Cystadenoma (benign) (serous) is a benign, cystic accumulation of retained secretions and cells on the outer surface of the ovaries.

Pseudomucinous is a benign, cystic accumulation of a variety of mucus.

Endometrial Cysts

Use 88305 for pathological examination of endometrial cysts, and 617.1 (endometriosis of ovary) for the diagnosis.

Endometrial cysts, also called chocolate cysts, result from endometrial implantation outside the uterus. The chocolate cyst of the ovary is associated with intracavitary hemorrhage and formation of hematoma containing old, brown blood. It is often seen with endometriosis of the ovary, but occasionally with other types of cysts.

Malignant Cysts

Pathological examination of these cysts should be coded 88307.

Primary malignant ovarian cysts are coded 183.0. An example is a malignant teratoma.

Secondary malignant ovarian cysts, such as a known intestinal malignancy with metastatic ovarian involvement. The appropriate diagnosis code is 198.6.

Ovarian cysts include numerous specific types, some of which are considered neoplastic, and some of which are not. Since coders may have to assign both diagnosis and procedure codes based on the pathologists report, they need to be familiar with the definitions and appropriate codes.