Wiki C-Section with Fibroid excision

[jilly78]

Hello Everyone,

I have a physician who performed low transverse cervical cesarean and also excision of 2 subserosal fibroids. I am not sure how to code for the fibroids the report states two fundal and slightly posterior subserosal fibroids were excised and oversewn with sutures. Any help would be appreciated!!

 

[csperoni]

I would code the fibroid removal during the c-section the same as any multiple procedure that is not a CCI edit.
1) Whatever the appropriate CS code is
2) 58140 Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; abdominal approach (or 58146 if the fibroids weighed >250gms, unlikely but possible).

 

[jilly78]

Thank you!!!

 

[natashalage]

Dear Csperoni and anybody who can explain to me why and when we bill 2 CPTs and when we don't. I will greatly appreciate your help.
I will explain my confusion in this example/case above. My thinking in this scenario is : when MD does C-S delivery, he opens the abdomen and uterus to extract the baby. 59514 has 16 RVU. For resection of uterine fibroids MD also need to open the uterus, 58146 has 15 RVU. High RVU were assigned to each CPT because of the complexity of the procedure: MD needs to open the cavity.
In our case MD already open the uterus for c-s delivery, then I ask myself that I should not give MD another 15 RVU for ectomy of fibroids because the uterus was already open, MD did less work, learned less RVU(not all 15 for 58146). It's the same organ-uterus. Should we add -22 to c-s delivery or 58146-52, yes I would like to use -52.
I hope you will see my confusion because I am a new coder and trying to see a logic, a rule. I heard someone somewhere said 'but the abdomen was already open!" I am learning and would like to see examples when we do bill 2-3 CPTs (granting all RVUs for each of them when abdomen is open) and when we don't ' because MD was already there"? The strange thing to me is that NCCI allows to bill these 2 CPT together without modifiers (kind of generous to pay for total 31 RVU for 2 open Px)
Thank you very much. Procedural coding is very challenging.

 

[csperoni]

You bill 2 (or more) CPT codes when the work performed is not better described by 1 code. For example, if there was a code for C-section with removal of fibroids, that is what you would use. Since there is not, you code both. Another example - laparoscopic hysterectomy with removal of tubes and ovaries. You would not code separately for laparoscopic hysterectomy and then laparoscopic tubes/ovaries since there is a code that describes both. Code:
58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
NOT 58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less and 58661 Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy). That would be unbundling.

When you bill multiple procedures, insurance will already automatically discount the 2nd procedure by 50%. You would NOT get paid for 31 RVUs in this example.
You would get paid 100% for the highest 59514 =16
50% for second 58146 = 7.5
Modifier -51 is to indicate it was a second/third/fourth procedure. In my experience, the insurance will automatically add on the -51 when processing.
I know my local MAC had advised many years ago for us NOT to add the -51, that the carrier would add it on their end. While you adding the -51 isn't wrong, there are situations where you may short yourself some payment. In the same example, if your fee schedule is not based on RVUs and the fee for 58146 is higher than 59514, you would not get the correct payment if you added -51 to 58146.
Here's a good AAPC article about the multiple procedure payment reduction: https://www.aapc.com/blog/41773-mppr-facts/

 

[natashalage]

What a great explanation, Christine! Thank you. I didn't know that insurance pays less on a second so forth procedure!.. They are smart. Now it makes sense. I vaguely remember this from my coding/reimbursement course in school but I have never used it in practice. Remarkable! Now I am in actual working field. Thank you very much for your detailed explanation, your time and patience with my questions that I have in OBGYN forum (and salpingectomy post). You help not only me but many other coders and we, all, benefit from your experience that you share with us. I wish I could give you a Big Hug; let it be a Big virtual one!
Thank you!