SGO Coding and Reimbursement
Questions and Answers by Category
Answers to incoming questions are provided by members of the SGO Coding and Reimbursement Taskforce and represent their opinions based upon the current
and usual practices in the field. Every effort is made to ensure the accuracy of the information provided. However, the information neither replaces information in
Medicare regulations, the CPT-4 code book, the ICD-9 CM or the ICD-10 CM code book; nor does it constitute legal advice. Responses to questions are intended
only as a guide and are not a substitute for specific accounting or legal opinions. SGO expressly disclaims all responsibility and liability arising from use of, or
reliance upon this information as a reference source, and assumes no responsibility or liability for any claims that may result directly or indirectly from use of this
information, including, but not limited to, claims of Medicare or insurance fraud.
References to ICD-9 codes are currently under review due to the transition to ICD-10.
Categories
Brachytherapy
Cervix
Chemotherapy
Evaluation and Management
Endometrial
Exenteration
General
Gastro-intestinal
Laparoscopy
Modifier
Ovary
Vulva
Other
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SGO Coding and Reimbursement
Questions and Answers by Category
BRACHYTHERAPY
Question
Answer
1
How do you code for insertion of a Smitt sleeve?
The SGO coding committee suggests that the insertion of the Smitt sleeve be reported either using code
57800-22 (dilation of cervix) or 58120-52 (Dilatation and curettage). The 22 modifier indicates increased
procedural service and the 52 denotes a reduced service. The 22 modifier will require a copy or the
procedure note in order to obtain additional reimbursement for the increased work. Not all payers utilized
modifier 52 when determining reimbursement so you may receive full payment even with the modifier.
2
How do you code for placement of Heyman’s capsules?
Report code 58346 (Insertion of Heyman capsules for clinical brachytherapy).
3
How do you code for placement of tandem/ovoids for
brachytherapy?
Gyn oncologists should use code 57155 (insertion of uterine tandems and/or vaginal ovoids for clinical
brachytherapy). Modifier 76 (repeat procedure by the same physician) may be necessary for subsequent
treatments. Radiation oncologists will bill for insertion of radioactive elements using separate codes
4
How do you bill for insertion of vaginal applicator device in
High Dose Rate (HDR) brachytherapy?
The surgeon should use code 57155 (insertion of uterine tandems and/or vaginal ovoids for clinical
brachytherapy) for insertion of tandem and ovoid. If a tandem is not placed, use a reduced service
modifier 52.
5
For insertion of cervical sleeve, should 57800 w/ 22 modifier
or 58120 w/ 52 modifier be used?
Also – how do you allow for the additional time to place seed
markers with these codes?
How does one bill for placement of fiducial markers at the time
of placement of a cervical sleeve for brachytherapy?
Use 57800, add -22 modifier.
Some recommend using 57155
Use 57410, examination under anesthesia for placement of fiduciaries.
CERVIX
Question
1
How do you code for a radical parametrectomy?
Answer
Report a code from the series 57107-57111 (vaginectomy with removal of paravaginal tissue)
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SGO Coding and Reimbursement
Questions and Answers by Category
CERVIX
Question
Answer
2
How should you code for EUA/cystoscopy/proctoscopy for
staging of cervical cancer?
EUA-57410. Cystoscopy (52000) and proctoscopy (45300) have separate procedure codes and are
frequently not reimbursed when used with 57410 for a diagnosis of cervical cancer. However, if there is a
separate diagnosis specific for cystoscopy or proctoscopy, (hematuria, melena, dysuria, constipation) you
may use code(s) 52000 and/or 45300 linked with code 57410 using the 59 modifier.
3
What code do you use to charge for a trucut needle biopsy of
the pelvic soft tissue performed along with an exam under
anesthesia?
Report code 20206 (Deep biopsy using percutaneous needle).
CHEMOTHERAPY
Question
Answer
1
We currently use ICD V58.11 for patients that are seen in the
office, by their physician, prior to receiving chemotherapy at the
hospital outpatient center. Is it correct to use V58.11 with their
E/M code when seen in the office?
You should routinely use the disease code (183, ovarian ca, for example) for an office visit, even if they
are coming to be evaluated for chemotherapy. The patient is still being treated by the physician for the
disease. You may also use v58.11 as a secondary code if you are giving chemo in the office. This is so
that drugs that are not obviously used for cancer like dexamethasone, ativan, etc, will be recognized as
such.
If you are sending the patient to a hospital and not billing for chemo administration yourself, you should
just report the disease code.
2
We are getting denials for office visits reported on the same
day as chemotherapy administration. The payer indicates that
the visits are included in the global period of the surgery. Any
suggestion on how to get the visits paid?
If the E/M service is for the purpose of evaluating the patient prior to chemotherapy or for counseling re:
chemotherapy, then you would report the E/M service with the modifier 24. However, you may want to
consider a diagnosis code other than the one used for surgery, such as the counseling code (V65.49) or a
sign/symptom resulting from the chemo.
If the E/M service is primarily a post-operative visit, then it is not reported separately. Any evaluation re:
chemotherapy would be included in that visit.
3
Do we still use 96445 even if we do not perform the
peritoneocentesis? Should we be adding the 52 modifier
(reduced service)?
SGO has discussed this with the AMA and other applicable specialty societies. All agree that code 96445
is the most appropriate code to report IP chemotherapy. This code was created during the time when the
standard of care required the testing of the patency of the catheter or fluid was sent for cytology prior to
administering the chemotherapy. The language for the code descriptor was intended to prevent
physicians from billing separately for the peritoneocentesis.
4
What ICD code do you use for laboratory testing done on a day
prior to chemotherapy administration?
You should always report the ICD code that most accurately reflects the reason for the service being
provided. In your example, that would be the most specific code for the disease or the presenting sign or
symptom. For example, if the patient has a low platelet/white count, then that should be used first followed
by the cancer diagnosis. In the absence of a sign or symptom, then the cancer diagnosis should be
primary. Code V58.11 is specifically for the encounter at which chemotherapy is being provided.
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SGO Coding and Reimbursement
Questions and Answers by Category
CHEMOTHERAPY
Question
Answer
5
What code should be used to bill a port flush by a nurse in the
absence of any other service?
If the patient is seen only for a port flush, code 96523 should be used. If you use a de-clotting or
thrombolytic agent, you should use code 36550. Also remember to use the J-code for the specific
thrombolytic agent used. The diagnosis code should be the patient’s primary cancer.
6
When administering chemotherapy in an office setting, what
are the requirements for the presence of the billing physician?
The physician is supposed to be “in the suite” as per Medicare rules. The interpretation of “in the suite”
can vary for individual practices, but should generally mean under the same roof. It is fraudulent to bill for
chemo administration if the physician is out of town, at the hospital, or otherwise out of the building.
7
Is it sufficient for a Physician Assistant-Certified to be onsite in
a clinic during a chemo infusion, or must a physician be
physically onsite?
Generally speaking, NPs, PAs and non-oncology physicians can provide supervision for chemotherapy
administration. You may want to clarify this with your individual Medicare carrier and other payers to make
certain there are no local policies that contradict with this information.
8
Can a gyn oncologist bill for chemotherapy counseling if that
counseling falls within the global period following a surgical
procedure?
Yes. Use the relevant E/M code with the 24 modifier for distinct E/M service during the global period. Also,
you must use an ICD-9 code for counseling, such as V65.49 (other specific counseling).
EVALUATION AND MANAGEMENT
1
Question
Answer
Can you bill for inpatient and outpatient E/M services provided
after surgery if the patient is seen for a post-operative
complication such as a wound infection? Is a modifier
required?
The CPT global surgical package includes all routine postoperative visits normally provided in conjunction
with the surgery. Medicare includes in this, the treatment of complications managed outside the
operating/procedure room. Medicare has set the global period as either 0, 10,or 90 days depending on
the specific procedure. Most other payers follow Medicare's post-operative periods.
Most major gyn/onc procedures have a 90-day global period. Therefore, visits in the hospital immediately
following surgery and routine outpatient visits are included in the payment for the applicable surgery and
should not be separately reported.
E/M services for post-operative complications such as wound infections and dehiscence cannot be
reported to Medicare until the patient is taken to the OR for a surgical procedure. Any procedure
performed in the operating room associated with these conditions can be reported by appending modifier
78 (Unplanned procedure).
For non-Medicare payers, you can report any additional E/M services above routine care for services
related to the surgery, such as wound infections. If visits for conditions unrelated to surgery are provided
in the global period, these can be reported by appending modifier 24. Modifier 24 is used for E/M services
provided in the global period that are "unrelated" to the surgery. No modifier is required for visits
associated with complications or other related conditions.
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SGO Coding and Reimbursement
Questions and Answers by Category
EVALUATION AND MANAGEMENT
Question
2
I heard that SGO suggests that all follow-up visits for cancer
surveillance be reported using code 99214 for up to 5 years?
Answer
SGO does not make blanket suggestions about the level of service selection for specific types of E/M
encounters. The level of service should be based on the CPT guidelines for selecting E/M codes and the
work necessary to appropriately evaluate and manage the patient. The CMS Documentation Guidelines
describe the documentation components for the various types of history, examination, and medical
decision-making. Medicare and most private payers use these guidelines when reviewing medical records
for levels of service. Note that CMS states, “Medical Necessity is the overarching criterion for payment in
addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate
to bill a higher level of evaluation and management (E/M) service when a lower level service is warranted.“
Page 5 of 24
SGO Coding and Reimbursement
Questions and Answers by Category
3
How do you differentiate between a new patient and a
consultation from another physician especially if I perform
surgery and follow with chemotherapy?
According to CPT, a consultation is a type of evaluation and management service provided by a physician
at the request of another physician (or appropriate source) to either recommend care for a specific
condition or problem or to determine whether to accept responsibility for ongoing management of the
patient's entire care or for the care of a specific condition or problem.
CPT further states you can initiate diagnostic or therapeutic services at that encounter or subsequent
encounters and still report a consultation code. It is expected that the requesting provider will use the
consultant's information in the care of the patient. This does not mean the referring physician has to
provide all the f/up care for the condition but that the information was valuable to them as they continued
to care for the patient.
If a provider is sending the patient to have a specific service provided and is not seeking input on a
specific problem, then consultation codes are not used. For example, a patient is sent by an internist for a
routine pap and pelvic exam. This is not a consult because there is no opinion being requested. A
patient with a gynecologic cancer sent to you by a physician, may very well be reported using a
consultation code. At that visit, you are likely making an independent evaluation of the best plan of care
which may include surgery. Based on your evaluation, you will provide your written recommendations
back (required to bill consult code) to the requesting physician. Once you have provided the initial
consultation, subsequent services will be reported using the appropriate established patient codes or
appropriate inpatient services.
Beginning January 1, 2010, Medicare no longer recognizes consultation codes. In the office or other
outpatient area, you should report the appropriate new or established outpatient code. In the inpatient
setting, Medicare instructs the consultant to report the appropriate initial inpatient code (99221-99223) for
the first encounter and then subsequent inpatient services (99231-99233) for any additional inpatient care.
4
Can consultation codes be reported to Medicare?
Beginning January 1, 2010, Medicare no longer recognizes consultation codes. In the office or other
outpatient area, you should report the appropriate new or established outpatient code. In the inpatient
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SGO Coding and Reimbursement
Questions and Answers by Category
EVALUATION AND MANAGEMENT
Question
Answer
setting, Medicare instructs the consultant to report the appropriate initial inpatient code (99221-99223) for
the first encounter and then subsequent inpatient services (99231-99233) for any additional inpatient care.
If the evaluation does not support the requirements for initial inpatient care, a subsequent care code can
be reported for the initial encounter with the patient.
5
Can the nurse or office staff document the History of Present
Illness (HPI)? We were told the physician must document the
HPI.
The Documentation Guidelines for Evaluation and Management Services state that the Review of
Systems (ROS) and the Past, Family, Social History (PFSH) can be recorded by ancillary staff or on a
form completed by the patient. It does not specifically indicate that the History of Present Illness (HPI) can
be recorded by staff. It is generally felt that the content of the HPI requires the expertise of a physician or
mid-level provider to appropriately address the patient's presenting problem. If the physician is noting
changes, additions, or agreement with the HPI then this may be seen as adequate in the event of a payer
audit. The physician should be encouraged to make the necessary additions or changes as he/she
interviews the patient.
6
Can the stage of the malignancy be used to indicate the
severity or progression of the disease and counted towards
the severity in the History of Present Illness component of an
E&M service when the patient presents with no symptoms (ie.
for a follow-up visit)?
Among the 8 possible elements of the HPI, the one referred to as "Severity", when applied to a patient
whose chief complaint is a cancer, usually relates to the extent of disease (i.e. Stage). It is correct to use
the stage of the malignancy as an HPI element.
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SGO Coding and Reimbursement
Questions and Answers by Category
EVALUATION AND MANAGEMENT
Question
Answer
7
How long can you use the cancer diagnosis (183.0) for a
patient once they have completed treatment?
There are 2 options that can be used, either the primary malignancy code or the personal history of
malignancy code. SGO and other oncology societies have taken the position that patients receiving
surveillance for a treated malignancy should have the ICD-9 code for that malignancy as their diagnostic
code. For example, a patient who is followed for ovarian cancer would have 183.0 as the diagnostic code
to justify the clinic visit. Patients who are under surveillance for cancer recurrence are not cured by
definition, since there would be no reason to do surveillance if they were cured. The length of time a
primary cancer code should be used is up to the individual physician to decide. More recently, some
institutions have taken the position that you should not use the cancer codes unless the patient has
documented evidence for a primary cancer or a recurrent cancer. Patients who have completed treatment
for the malignancy, are now considered to have a personal history of cancer (for example, V10.43-ovarian
cancer, personal history). Either choice is acceptable and both codes appear to be covered by the
majority of payors.
8
When leveling out an E&M, on the risk of complications and/or
morbidity or mortality table, a gyn/onc physician discusses
with a patient all the risk and complications of a surgery, and
the patient decides against surgery. Would you still give
elective major surgery with identified risk, even if the decision
was not made for surgery or whichever surgery it classifies
as?
A physician sees a patient that another doctor sends to her
with the knowledge of a pelvic mass that the doctor is
requesting to be removed with surgery, previously discussed
between the 2 physicians. The physician has the 3 R’s in her
documentation. Would this be considered a consult or new?
Yes, you would code it as if the surgery was elected. The point is not what the patient ultimately decided,
but the work done by the physician. Of course, the option for surgery (and thus need for counseling) must
be medically appropriate.
9
Or would the documentation need to state that the physician
would like to render an opinion?
It would depend on the expectation of the referring physician. Normally this would be a consultation if the
referring physician is requesting an opinion regarding the management of this mass. The consultant can
then proceed with diagnostic/therapeutic management if appropriate. If the referring physician is
transferring care of the patient, then it would be a new patient visit.
Since the 3’Rs are included, then this would be a consultation.
1. The name of the Requesting attending (residents cannot request billable consults);
2. His/her opinion and/or Recommendations; and
3. Evidence that a written Report was submitted to the requesting physician.
If a physician agrees to accept transfer of care before an initial evaluation the new patient codes should be
used but consultation codes are appropriate to report if the decision of transfer of care cannot be made
until after an initial evaluation. CPT has a great discussion of consult versus transfer of care in the CPT
book.
Unfortunately, CMS no longer reimburses consult codes so this distinction is moot for Medicare patients.
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SGO Coding and Reimbursement
Questions and Answers by Category
ENDOMETRIAL
Question
Answer
1
How do you code for a laparoscopic hysterectomy/BSO and
pelvic and para-aortic lymphadenectomy done for endometrial
cancer?
You should code separately for the laparoscopic hysterectomy and the laparoscopic node dissection
depending on exactly what was done. You CANNOT do this for an open TAH/BSO, and nodes, because
there are specific codes for this (58200 or 58210), and coding separately for the hysterectomy and nodes
is unbundling.
2
How do you code for a laparotomy with pelvic and para-aortic
lymphadenectomy and omentectomy for endometrial cancer
when a TAH/BSO was done by the Ob/Gyn?
In this instance, the OB/Gyn reports code 58150 for the TAH. The Gyn/Oncologist reports either code
38780 (Retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal
nodes (separate procedure)) for the retroperitoneal lymphadenectomy or 38770 (Pelvic lymphadenectomy,
including external iliac, hypogastric, and obturator nodes (separate procedure)). Code 38780 includes
renal nodes, so by CPT guidelines you should append the 52 modifier (reduced services). Code 38770
does not include the paraaortic nodes. However, of note, 38770 can be reported with the bilateral modifier
(50) but 38780 cannot. Reimbursement using the 50 modifier typically results in 150% of the allowable
amount. The 2010 RVUs for 38770 are 22.19 and 38780 are 28.23. Therefore, you would actually get
better reimbursement reporting 38770-50 and certainly less reimbursement risk than if you used a 52
modifier.
If there is cancer in the omentum (ICD-9 235.4), then you can bill separately for the omentectomy, and you
would then append a 59 modifier to 49255. If the omentectomy is done for staging, and the final path
report shows no cancer, then it will be difficult to get paid for the omentectomy.
3
What is the correct way to code a TAH/BSO with
omentectomy and full staging for a diagnosis of papillary
serous endometrial carcinoma?
The typical CPT code for surgical treatment of endometrial cancer is 58200 or 58210 depending upon the
extent of the lymphadenectomy. These codes include a TAH/BSO and sampling or removal of pelvic
lymph nodes and paraaortic nodes. If a lymphadenectomy is performed instead of lymph node sampling,
then code 58210 is used. An omentectomy is considered to be a "separate procedure" under the Correct
Coding Initiative (CCI), which means that it should not be reimbursed if billed separately in usual
situations. Therefore, obtaining reimbursement for an omentectomy during an endometrial cancer surgery
will be problematic, especially if performed for staging purposes (i.e., no gross metastatic disease). One
situation that may be reimbursable is when the omentectomy is performed for metastatic disease. Under
this scenario, use the omentectomy code 49255 with the 59 modifier, plus the ICD-9 code that justifies the
procedure (i.e., 197.6, secondary malignancy of the omentum). Medicare will never reimburse for an
omentectomy done at the time of a hysterectomy but other payors might under this circumstance.
Page 9 of 24
SGO Coding and Reimbursement
Questions and Answers by Category
ENDOMETRIAL
4
Question
Answer
Regarding open hysterectomies done with staging
lymphadenectomies for endometrial cancer, an HMO payer
who is declining reimbursement stating that there is an edit for
the 2 codes used. The codes are 58150 and 38562.
58200 or 58210 for open hysterectomy with pelvic lymphadenectomy and para-aortic node sampling.
If you do an open hysterectomy with pelvic lymphadenectomy then you should bill a 58210 if you are doing
a hysts and pelvic and paraaortic lymph node sampling then use 58210.
I was told that the AMA CPT coding book states that 58150
include lymphadenectomies as "incidental."
5
How do you code for IUD placement for endometrial
hyperplasia or cancer, not for contraceptive purposes?
58200 is used for abdominal hysterectomy with pelvic and para-aortic node sampling.
58210 is used for radical hysterectomy with bilateral total pelvic lymphadenectomy and para-aortic node
sampling. In previous CPT versions this included simple hysterectomy and was the recommended code
for use in open endometrial cancers if an extended pelvic node dissection was performed. While many
gynecologic oncologists probably still use this code, the current manual terminology has changed and its
use would likely be dependent on the description of the hysterectomy performed and the extent of the
node dissection beyond a simple node sampling.
Use of 58150 with 38562 would be considered “unbundling” and is not acceptable coding.
58300 is the CPT. The ICD9 code is V25.11. The patient’s diagnosis code may or may not make a
difference to the insurer since this is an off label use. If they are reproductive age you could present this
also as contraception device.
EXENTERATION
Question
Answer
1
How do you code for placement of a matrix (graft) during
pelvic exenteration and reconstruction?
Placement of material in the pelvis to prevent bowel obstruction would be considered an inherent part of
the procedure, and should not be billed separately. Therefore, you should report only code 58240 for the
pelvic exenteration. An exception would be placement of an omental pedicle flap in the pelvis (+49905).
2
Would it be appropriate to code construction of the vagina
(57292) with pelvic exenteration (58240) or is the construction
of the vagina bundled into the exenteration code?
Vaginal reconstruction is not included in the pelvic exenteration code, and can therefore be coded
separately for construction of an artificial vagina with a skin graft (57292). If anything other than a skin
graft is performed (e.g. myocutaneous flaps) this should be coded separately (i.e. 15734). The 51 modifier
needs to be used for each additional procedure.
Page 10 of 24
SGO Coding and Reimbursement
Questions and Answers by Category
GENERAL
Question
Answer
1
Is it appropriate to append the 22 modifier to code 58210
when a total omentectomy is performed? Our practice has
been unsuccessful in getting additional reimbursement from
either Medicare or the commercial payers.
One of the problems lies in the fact that Medicare's CCI bundles an omentectomy into code 58210 and will
not allow it to be paid even with a modifier. Therefore, they may not be willing to pay additionally for the
omentectomy even though the code does not include a total omentectomy. A number of other payers also
use the CCI as part of the claims review process. You might try having the surgeon dictate a general
letter indicating the need for the total omentectomy and the work involved including the additional time and
risk. The letter should clearly indicate that the procedure is not a partial omentectomy. Another coding
alternative might be code 58954 but this includes a debulking and assumes there is intra-abdominal
disease.
2
How do you code for a radical hysterectomy when there was
not a node dissection performed because the patient had preop radiation?
There is not a specific CPT code for a radical hysterectomy without lymphadenectomy. The best choice
would be to report code 58210 with the reduced service modifier 52. This assumes that the parametria
were excised and the ureters were dissected as is done typically with a radical hysterectomy. If this as not
done, then it should be coded as 58150-22.
3
Is it appropriate to report code 38562 when a complete
lymphadenectomy is done in conjunction with 58150?
Code 38562 is described as a "limited lymphadenectomy" that is performed for staging. In addition, it is
designated as a separate procedure in CPT and may therefore be bundled into other procedures reported
on the same day. If performed with a simple hysterectomy (58150), then 58200 should be used. It is likely
that code 58210 is most appropriate if the parametria were excised and the ureters were dissected as is
done typically with a radical hysterectomy. In general, codes 38570-38572 are most commonly reported
when it is appropriate to report nodes separately from other procedures.
4
How do you code for a laparoscopic (robotic assisted)
trachelectomy, BSO, and lymphadenectomy? I was
considering reporting codes 58661, 57530, and 38571 but a
colleague suggested code 58552 with 38571.
58548 with a reduced services modifier -52 is advised.
It would not be appropriate to report code 58552 (Laparoscopy surgical; with vaginal hysterectomy, for
uterus 250 grams or less; with removal of tube(s) and/or ovary(s)) since a hysterectomy was not
performed.
As you suggested, the BSO would be reported using code 58661 (Laparoscopy, surgical; with removal of
adnexal structures (partial or total oophorectomy and/or salpingectomy) and the bilateral pelvic
lymphadenectomy with code 38571 (Laparoscopy surgical; with bilateral total pelvic lymphadenectomy).
Since there is not a code for a laparoscopic trachelectomy, a code using a different approach would have
to be used. Code 57530 is intended to be used when the uterus is still in place and the surgeon simply
removes the cervix and leaves the uterus in place. In this case, the uterus was previously removed. A
“Cervical stump” occurs when the uterus was removed from the cervix and the cervix was left in place.
Therefore, you would choose either 57550 (Excision of cervical stump, vaginal approach;) or 57540
(Excision of cervical stump, abdominal approach) depending on which best represents the work performed
by the surgeon. In either case, you might want to submit a special report indicating that portion was done
via a laparoscopic approach.
There are not codes specific to the use of the robotic arm.
5
How do you code for a robotic trachelectomy when the uterus
has been previously removed?
Since there is not a code for a laparoscopic approach, the unlisted code 58578 (unlisted laparoscopy
procedure). The unlisted code will require a special report and payment may be delayed.
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SGO Coding and Reimbursement
Questions and Answers by Category
GENERAL
Question
Answer
6
What is the difference between codes 58552 (Laparoscopy
surgical, with vaginal hysterectomy, for uterus 250 grams or
less; with removal of tube(s) and/or ovary(s)) and 58571
(Laparoscopy, surgical, with total hysterectomy, for uterus 250
g or less; with removal of tube(s) and/or ovary(s))?
Codes 58550-58554 describe laparoscopically assisted vaginal hysterectomy which includes a
laparoscopic detachment of ovarian vessels and skeletonization of the uterine attachments. The uterus is
removed vaginally.
Codes 58570-58573 describe services in which the uterine fundus and cervix are all performed
laparoscopically and the vaginal cuff is sewn laparoscopically. Often, the specimen is removed via the
vagina. Codes 58570-58573 are typically performed using the robot.
7
What is the most appropriate code for thickened endometrial
stripe?
The code is 793.5 (abnormal findings on radiograph, genitourinary).
8
Is it appropriate to use code 209.29 for Vipoma?
A true VIPoma is a tumor of the endocrine pancreas cells. Code 209.29 would not be appropriate. Code
209.29 is for carcinoids (malignant carcinoid tumor of other sites). A Vipoma may show signs of carcinoid
syndrome, but is not a carcinoid, per se. Codes C25.4 (malignant neoplasm, endocrine pancreas) or
E16.8 (other disorders of pancreatic intestinal secretion) would be more appropriate.
9
What is the difference between codes 58950-58952 and
codes 58953 and 58954?
Codes 58953-58954 include a hysterectomy as a required component and radical debulking of the
tumor(s). Codes 58950 and 58952 do not include a hysterectomy. While code 58951 does describe a
hysterectomy and lymphadenectomy, it does not represent a radical debulking as described by codes
58953-58954. Code 58951 is more appropriate when you fully stage an otherwise clinical stage 1 ovarian
cancer. It is recommended that you discuss these distinctions with the surgeons and request that the
surgical procedure be described using the language found in CPT. This will help you to better assist in the
proper selection of the surgical codes.
10
Can you report a cystoscopy at the time of a pelvic procedure
to make sure there is no injury to the ureters?
A cystoscopy performed routinely at the time of a surgical procedure is not separately reportable. When
procedures are done to "check" one's work, it is considered inherent in the procedure. Additionally, there
is not an ICD code that can be appended to support a clinical need for the service. If there has been an
injury to the ureters at the time of the surgery, then it would be appropriate to report the cystoscopy with
the appropriate ICD code, such as hematuria.
11
Is code 58720 bundled into code 49203?
CPT lists a number of procedure codes that should not be reported in conjunction with code 49203
(Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal,
mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less). Code
58720 (Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)) is not
among them however codes 58900-58960 are listed. These codes describe ovarian work including 58940
(Oophorectomy, partial or total, unilateral or bilateral). Therefore, it would be reasonable to assume that
code 58720 should not be reported in conjunction with code 49203. In addition, Medicare's Correct
Coding Initiative (CCI) bundles 58720 into the payment for 49203 and does not allow it to be reported with
a modifier.
Page 12 of 24
SGO Coding and Reimbursement
Questions and Answers by Category
GENERAL
Question
Answer
12
What is meant by “bundle/unbundle? I reported codes 58952,
44950, and 44120 and received a note from a managed care
payer stating that 44120 is a “Medicare Unbundle Code”.
In answer to your underlying question regarding "Medicare Bundled Code", Medicare determines lesser
services to be included in the payment (bundled) for more comprehensive services. The codes that are
considered "bundled" into a specific procedure are noted in Medicare's bundling guidelines, known as the
National Correct Coding Initiative (CCI). In some instances, both the comprehensive procedure and the
lesser procedures can be reported if a modifier is appended. Modifier 59 is the most common modifier
used for this purpose.
In the code combination you noted, Medicare's CCI actually bundles 44950 into the payment for 58953.
This is because an "incidental" appendectomy is not separately payable when another surgery is
performed. If the appendectomy was done for an indicated purpose (inflamed, diseased, etc.), then the
proper CPT code is 44955 (Appendectomy; when done for indicated purpose at time of other major
procedure (not as separate procedure) (List separately in addition to code for primary procedure). A
modifier is not required since this is an add-on code. Based on your question, it seems that 44950 was
reimbursed even though it may not be the most accurate code for the surgery.
Under CCI guidelines, Code 44120 can be reported in addition to 58953 using the 51 modifier. The denial
of this code may have to do with code 44950 as it is bundled into many of the GI codes. I suggest that
you review the operative note for clarification. The full CCI, along with background information, is
available on the CMS website and noted as the National Correct Coding Initiative.
13
Is there a difference in coding for a pelvic lymphadenectomy
vs. a pelvic lymph node sampling?
These services represent different procedures and different work. This is most obvious when you look at
the laparoscopic lymphadenectomy codes (38570-38572). If this service is provided with a TAH/BSO for
endometrial cancer, code 58200 is used for sampling, whereas code 58210 is used for lympahdenectomy.
The lymph node sampling is considered a biopsy as the CPT language suggests and lymphadenectomy is
the dissection out of the lymph nodes. However, one should not use 58200 with laparoscopy codes.
14
What code would you report for the removal of 2 large pelvic
nodes at the time of a TAH/BSO on a patient with postmenopausal bleeding? The nodes were benign.
The best option would be code 38500 (Biopsy or excision of lymph node(s); open, superficial). You should
append modifier 51 (multiple procedures) to code 38500 and associate with the appropriate ICD code,
such as 785.6 (enlargement of lymph nodes).
15
Can one report a radical debulking code (58952-58954) when
there is no tumor outside the ovary?
The radical ovarian tumor debulking codes are designed for when there is tumor outside of the
ovary/fallopian tube/endometrium. If there is only staging performed, then the more appropriate codes are
58943 or 58950-59951.
16
What code is reported when a
TAH/BSO/Omentectomy/Staging is performed for LMP or
borderline tumor?
This is a common concern because none of the existing codes fit this exactly. Code 58956 includes a
TAH/BSO with total omentectomy. If this is the only staging performed, then this would be appropriate. A
more likely choice would be code 58951, which includes a TAH/BSO, omentectomy, and P&P nodes, but
does not include peritoneal biopsies. Code 58943 also describes the procedure, but does not include the
TAH, and therefore is problematic. If lymph node dissection was not done, then one could code 58952-52
(reduced services).
Page 13 of 24
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Questions and Answers by Category
GENERAL
Question
17
Can ureterolyisis (50715) be reported in addition to code
58150 (TAH/BSO?
Answer
Code 50715 is a code used to manage ureteral obstruction secondary to retroperitoneal fibrosis. Absent
this indication, the code should not be reported. If the need to dissect the ureters added significant work
to the hysterectomy you may append a 22 modifier to code 58150 to indicate the increased difficulty of the
procedure.
58210 may also be used with a reduced services modified, depending on what precisely was performed.
18
Can management of total parenteral nutrition be reported for a
post-op patient?
This is considered part of the global package reported by the surgeon. For pre- op patients or patients not
having surgery, you can bill use the 99221-99233 series. It may be more cost-effective to consult another
physician for management of parenteral nutrition, and allow that person to manage and bill for those
services.
19
There seems to be much debate regarding V codes versus
cancer diagnosis codes. It has even been suggested that we
use V codes or history of cancer in our postop visits,
assessment for disease status, assessment of symptoms and
response to therapy. When would we use a diagnosis code
then? Is there a specific time frame attached to the
diagnosis? Is there additionally terminology about the disease
status or stage or risk that is part of the cancer diagnosis?
It is reasonable to use the diagnosis code in the first 5 years after diagnosis when the patient is being
actively followed for risk of recurrence (tumor markers, x-ray monitoring, etc) and medical decision making
is directed towards that end.
Beyond that point, if the patient is being seen for well-woman or other problems, then a V code is
appropriate along with the appropriate problem ICD-9 code.
Generally once active treatment of a disease is complete and there is NED then you would use the
personal Hx codes. Usually there are no reimbursement issue when the personal Hx codes are used.
20
Physician performed a fiducial marker of the vagina. She
didn’t place anything, only did the marking. What should be
billed?
A gynecologic oncologist was called into the OR following a
supracervical hysterectomy for 36 week previa and accreta for
control of hemorrhage and removal of residual cervix. How
should we bill for this?
57410, examination under anesthesia.
21
Code for intra-operative consultation:
Dictate consultation note.
Use appropriate consultation code with -57 modifier.
Bill for procedure:
TAH 58150 with -62 Co-Surgeon modifier.
Exploration of retroperitoneum 49010 if appropriate. Retroperitoneal exploration is a separate procedure
and so cannot be billed with the hysterectomy but you can bill this if it is the only thing that you are billing.
Page 14 of 24
SGO Coding and Reimbursement
Questions and Answers by Category
GENERAL
22
23
Question
Answer
Assistance is needed in coding for both Dr. A and Dr. B in this
complicated surgery:
Surgeon A should bill 58240 and include the op note with the claim, recognizing that there is no CPT code
for a robotic pelvic exenteration.
PREOPERATIVE DIAGNOSIS: Recurrent cervical carcinoma
POSTOPERATIVE DIAGNOSIS: Recurrent cervical
carcinoma
PROCEDURE PERFORMED:
1. Diagnostic laparoscopy
2. Robotically assisted laparoscopic para-aortic
lymphadenectomy
3. Multiple (6) peritoneal biopsies
4. Anterior supralevator pelvic exenteration
5. Proctoscopy
6. Exploratory laparotomy
7. Small bowel resection and reanastomosis
8. Placement of Turnbull urostomy
SURGEON: Dr A, M.D. And Dr B, M.D. (second faculty
required due to complexity of case and no available qualified
resident)
ASSISTANT: 2 residents
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 400 mL
INTRAVENOUS FLUIDS: 2100 mL crystalloid, 5000 mL
colloid
URINE OUTPUT: Unmeasured due to nature of case
COMPLICATIONS: None
DISPOSITION: Stable to PACU
Surgeon B should separately bill an ileal conduit – 50820.
For patients with a history of malignancy; coders are advised
to use the personal history codes (example V10.41) when the
patient has no evidence of disease and is not receiving active
treatment. If the patient had a malignancy within 5 years may
providers use a malignancy code for asymptomatic
surveillance visits?
It is reasonable to use the diagnosis code in the first 5 years after diagnosis when the patient is being
actively followed for risk of recurrence (tumor markers, x-ray monitoring, etc) and medical decision making
is directed towards that end.
None of the other procedures listed are billable.
As residents are listed as assistants in the op note, neither surgeon A or B would be able to bill as an
assistant.
Beyond that point, if the patient is being seen for well-woman or other problems, then a V code is
appropriate along with the appropriate problem ICD-9 code.
Generally once a patient is no longer receiving treatment for a specific disease a personal hx code is
appropriate to use. There should be no issues with reimbursement for these codes.
Page 15 of 24
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Questions and Answers by Category
GENERAL
24
Question
Answer
Please clarify which code to use for hysteroscopy with D&C. I
came up with 4 codes for these procedures. Could you
confirm if my coding is accurate in capturing all procedures?
58545 (OK as coded)
58662-51 (should be ok with the multiple procedure modifier 51. CCI edits for 58545 and 58662 aren’t
bundled)
58558 (hysteroscopy with D&C; 58555 and 58120 shouldn’t be listed separately) - would also include the
multiple procedure modifier
Procedures:
Robotic Myomectomy
Right Ovarian cystectomy
Lysis of adhesions with re-development of the posterior culde-sac
Hysterectomy
D&C
The 58558 code is for the hysteroscopy and D & C. The 58545 is for the laparoscopic myomectomy and
the 58661 or 58662 is for the laparoscopic cystectomy. You may prefer 58661, (partial removal of ovary)
rather than 58662 (excision of lesions of the ovary). List the code with the greatest RVU's first without a
modifier. The remaining two codes should have a 51 modifier.
58545 ( myomectomy, laparoscopic)
58662 (cystectomy, laparoscopic)
58555 (hysteroscopy, diagnostic)
58120 (D&C, diagnostic)
GASTRO-INTESTINAL
Question
Answer
1
How do you code for a Hartmann procedure done in
conjunction with a radical hysterectomy?
The Hartmann procedure is reported with code 44143. The 51 modifier (multiple procedure) should be
appended to code 44143 as it has fewer RVUs than the radical hysterectomy (58210).
2
How do you code for a mesh closure done at the time of a
loop ileostomy and mucofistula?
There is no separate code for mesh closure of an abdominal wound. The surgery is best coded by
reporting code 44310 with a 22 modifier for the mucous fistula and complex abdominal wall closure. If a
22 modifier is reported the documentation must reflect significant additional work and the reason for the
additional work. It may be helpful to send a cover letter highlighting the work associated with the complex
wound closure and the mucous fistula.
3
How do you code for an ileo jejunal bypass anastamosis and
drainage of small bowel fistula with malecot drain on a patient
with a history of cervical cancer with secondary small bowel
obstruction secondary to severe radiation enteritis?
Based on your scenario, it is assumed that a resection was performed. In that situation, code 44120
(Enterectomy, resection of small intestine; single resection and anastomosis) would be the most
appropriate code. The fistula drainage and placement of the associated drain are not separately reported
but rather are considered to be part of the primary procedure.
Page 16 of 24
SGO Coding and Reimbursement
Questions and Answers by Category
GASTRO-INTESTINAL
Question
Answer
4
Can you report an appendectomy done at the time of surgery
for tumor reduction when the appendix was involved with the
tumor?
Yes, there is a specific CPT code that should be used in these circumstances. The code is 44955
(Appendectomy, when done for indicated purpose at time of other major procedure). This is an add-on
code and therefore does not require the 51 modifier and is not subject to a multiple procedure reduction.
You should associate the appropriate cancer diagnosis with the appendectomy to support the fact that it is
not an incidental appendectomy.
5
Can you code for an appendectomy if the reason it is being
taken is to avoid possible appendiceal mucinous lesions?
In the situation that you describe, it sounds as if you are coding for an incidental appendectomy. In the
CPT book it clearly states: " an incidental appendectomy during intra-abdominal surgery does not usually
warrant a separate identification.” When an appendectomy is performed for an indicated procedure, i.e.
tumor metastatic to the appendix or involvement with endometriosis, at the time of another major
procedure, then you would use code 44955. This is an "add-on" code and therefore does not require a 51
modifier.
6
How should you code for an ileotransverse entero-colostomy
without a bowel resection?
You would report code 44130 (Enteroenterostomy, anastomosis of intestine, with or without cutaneous
enterostomy (separate procedure))
LAPAROSCOPY
Question
Answer
1
Is there a corresponding laparoscopic code for codes 58952
(Resection (initial) of ovarian, tubal or primary peritoneal
malignancy with bilateral salpingo-oophorectomy and
omentectomy; with radical dissection for debulking (ie, radical
excision or destruction, intra-abdominal or retroperitoneal
tumors) and 44955 (Appendectomy; when done for indicated
purpose at time of other major procedure (not as separate
procedure) (List separately in addition to code for primary
procedure)?
You should report the unlisted code 58679 (unlisted procedure, ovary) if there is not a laparoscopic code
available to describe the procedure performed. If an unlisted procedure code is reported, the claim should
be filed manually (paper claim) with a copy of the operative note and a brief explanation of the procedure
and reason for the unlisted code. You should base your fee on a comparable open procedure code.
For a laparoscopic appendectomy at the time of another procedure, the coding choice is code 44970
(laparoscopic surgical appendectomy). You will need to append modifier 59 to this code to indicate it is
separate and distinct from the other surgery. The operative report documentation should clearly describe
the procedure and the reason for performing it. You should also append a distinct ICD code if available.
2
Is there a laparoscopic code for the open procedure code
58825 (Transposition, ovary(s))?
There is not a corresponding code for a laparoscopic 58825. You can report code 58679 (Unlisted
Laparoscopy procedure, oviduct, ovary). If an unlisted procedure code is reported, the claim should be
filed manually (paper claim) with a copy of the operative note and a brief explanation of the procedure and
reason for the unlisted code.
Alternatively, you might report code 58660 (Laparoscopy, surgical; with lysis of adhesions (salpingolysis,
ovariolysis) (separate procedure) to justify any manipulation of the ovary. The lysis of adhesions must be
well documented. As a point of information, the RVUs for codes 58825 and 58860 are very similar.
Page 17 of 24
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Questions and Answers by Category
LAPAROSCOPY
Question
Answer
3
How do I code for a laparoscopic omentectomy done at the
time of a laparoscopic BSO and pelvic and para-aortic lymph
node dissection for a borderline tumor?
There is not a code for laparoscopic omentectomy. You can elect to report code 49329 (unlisted
laparoscopy procedure, abdomen, omentum, peritoneum) for the omentectomy in addition to the codes for
the other procedures. You will need to send a copy of the operative report and a special report.
Alternatively, you might report code 49321-22 (Laparoscopy, surgical; with biopsy (single or multiple).
The payer may not provide additional reimbursement for the omentectomy.
Medicare’s CCI bundles an omentectomy in the payment for all open hysterectomy codes. If the payer
follows this CCI logic, then payment will not likely be made for the omentectomy.
4
How do you code for a laparoscopic ureterolysis?
You should report an unlisted code for procedures that do not have specific laparoscopic CPT codes. It is
not appropriate to report the open code in these instances. A laparoscopic ureterolysis should be reported
using the unlisted code 50949 (Unlisted laparoscopy procedure, ureter).
The open version of this code falls under the “may be paid” category under Medicare's CCI and is
intended for the diagnosis of retroperitoneal fibrosis. In general, the same should apply to laparoscopic
ureterolysis. Therefore, depending on the circumstances you may not be reimbursed for the ureterolysis.
You should make certain that the appropriate ICD code is reported for the procedure.
5
Is it permissible to report an open procedure code when there
is not a corresponding laparoscopic code?
CPT guidelines indicate that an unlisted code be reported when there is not a specific CPT code for the
service provided. More specifically, the guidelines indicate that it is not appropriate to report an open
procedure code for a procedure performed laparoscopically. In these instances, the coder is instructed to
report the appropriate unlisted code. You will need to send in a special report or cover letter as well as the
operative report to describe the need for the unlisted code.
6
What code do you use for laparoscopic staging of ovarian
cancer?
There are no specific CPT codes that describe laparoscopic staging/surgery for ovarian cancer or
debulking. The final code depends on whether the uterus, tubes/ovaries were removed as part of the
procedure or not. If so, then you can use the laparoscopic hysterectomy codes (either LAVH-5855058554 series or TLH-58570-58573 series), or laparoscopic BSO (58661), PLUS laparoscopic P&P nodes
(38572), and 49329 (unlisted laparoscopy procedure, abdomen, peritoneum, omentum) for the
omentectomy and peritoneal biopsies.
7
What codes do you recommend for surgeons to use for robotic
assisted surgery?
There are no specific codes or modifiers to use for robotic surgery. You should select the appropriate
laparoscopic code for the surgery you performed. If the work required to perform the procedure was
substantially greater than typically required, you can append the 22 modifier and describe the increased
work and the reason for the additional work. The modifier should not be used solely because the
procedure was done using a robotic approach.
Page 18 of 24
SGO Coding and Reimbursement
Questions and Answers by Category
LAPAROSCOPY
Question
Answer
8
Could you comment on the use of the S2900 code as an
additional code for robotic surgery?
The "S" codes are created for use for payers other than Medicare. The recognition and utilization of these
codes vary according to the payer. You would report code S2900 as a secondary CPT code when you
perform a surgery using robotics. It is not necessary to append a modifier. You should apply some
incremental charge to the code for the work associated with the robotic approach that is different from the
basic surgery you report. Reimbursement will vary by payer.
CPT has made the decision not to have a modifier or specific codes for robotic surgery thereby restricting
any additional payment for this technique.
9
How do you code for a laparoscopic hysterectomy, BSO,
bilateral total pelvic lymphadenectomy and paraortic lymph
node sampling using a robotic arm?
You should report either CPT codes 58571 (Laparoscopy, surgical, with total hysterectomy, for uterus 250
g or less; with removal of tube(s) and/or ovary(s)) or 58573 (Laparoscopy, surgical, with total
hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)) depending on the
size of the uterus. Code 38571 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy)
should be reported as the second procedure with modifier 51. Code 38572 (Laparoscopy, surgical; with
bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple)
would be reported if para-aortic node sampling was also done. There is no code or modifier for use of the
robotic arm. These services are reported using the applicable laparoscopic codes.
10
Can robotic surgery be performed as an outpatient procedure?
Our hospital billers insist that it is an inpatient procedure and
should be documented to that effect.
The status of the patient with the hospital (inpatient or outpatient) is what determines how the claim should
be billed and how the operative report and medical records are documented. As there are not specific
codes for robotic surgery, the appropriate laparascopic code should be reported for the surgery performed.
Some laparoscopic procedures are commonly performed as outpatient surgery. The codes for total
laparoscopic hysterectomy (58570-58573) were valued to include a brief inpatient hospital stay.
You should explore with the hospital’s billing department the background and issues associated with the
request. It may be that the hospital has designated the patient as an inpatient for these procedures, thus
creating a mismatch between the hospital and physician billing. It is also possible that a payer may not
reimburse the hospital unless the surgery if performed on an inpatient basis.
11
What is the most appropriate way to code laparoscopy with
laparoscopic right salpingo-oophorectomy, left ovarian
cystectomy, omentectomy and ovarian cancer peritoneal
staging biopsies?
There is no comprehensive code. There is no laparoscopic code for omentectomy. Use 58600 for the
laparoscopic RSO, cystectomy and a -22 modifier for the staging biopsies, assuming that this increased
the amount of time and work involved. The omentectomy can be billed with an unlisted laparoscopic code
and the RVUs and charges should be tied to the open procedure.
12
How do you code for robotically-assisted total laparoscopic
hysterectomy, bilateral salpingo-oophorectomy, pelvic and
aortic lymph node dissection?
How do you code for robotically-assisted total laparoscopic
hysterectomy, bilateral salpingo-oophorectomy, pelvic and
aortic lymph node dissection, omentectomy and multiple
peritoneal biopsies?
Use 58571/3 and 38572.
13
Use 58571/3 with 38572 and the unlisted laparoscopic code for omentectomy and use the RVUs and
charges for an open omentectomy.
Page 19 of 24
SGO Coding and Reimbursement
Questions and Answers by Category
LAPAROSCOPY
Question
Answer
14
Regarding billing for a gelport robotic assisted salpingooophorectomy; as this type of equipment requires a larger
incision than other types of laparoscopy, can this procedure
be billed as “open” vs “laparoscopic” CPT code?
The op-report should dictate the billing. Robotics is not billed any different than laparoscopy. Based on the
fact that a robotic USO was done, it is recommended to submit a 58661 with a 22 modifier and submit the
op report with it. It is not recommended to code this as an open procedure.
15
What code should be used to report a vaginal incision or
“episiotomy” after Robotic Hysterectomy?
Not separately billable. It is necessary to perform the planned procedure and is not billable.
If using code 58548, is it okay to bill for the incision to remove
the uterus?
Unless the incision or repair was done for a separate indication or diagnosis, it won’t be billable as part of
58548.
MODIFIER
Question
Answer
1
Is the 22 modifier appropriate if you convert from a
laparoscopic to an open procedure with diagnosis code
V64.41 (Laparoscopic surgical procedure converted to open
procedure)? Does the operative report need to indicate
additional time or just state that the procedure was converted?
The 22 modifier is appended when the work to perform the procedure was substantially greater than that
typically required. The conversion from laparoscopic to an open procedure might be an instance in which
the 22 modifier is appended, but the documentation will need to reflect “substantial” additional work as
specified in CPT. CPT also states that the reason for the additional work such be documented. It lists
increased intensity, time, technical difficulty, severity of patient's condition, and physical and mental effort
as reasons for additional work. (See modifier 22 descriptor in Appendix A). The note does not specifically
need to indicate additional time if any of the above reasons for the additional work is documented.
2
For open hysterectomy on an obese patient with a 24 week
uterus and a 30cm incision, can we be reimbursed for the
closure/repair of the surgical site? The closure takes a good
amount of time and utilizes sutures and staples. Many
general surgery codes have repair codes or use the
intermediate and complex repair of the trunk CPT codes
12031-12037, or 13000-13102.
A -22 modifier could be used if the procedure is more extensive than normal if the additional time and work
involved is documented. A separate code for closure is not billable in this circumstance.
Page 20 of 24
SGO Coding and Reimbursement
Questions and Answers by Category
MODIFIER
Question
3
A unilateral sentinel lymph node biopsy with injection of blue
dye for sentinel node identification was performed. The
sentinel node was positive for cancer, thus the physician
proceeded to perform bilateral superficial inguinal
lymphadenectomy.
Answer
Your coding is correct; 38760-50 first with the add on code of 38900. If 38900 is denied, the determination
should be disputed.
Code 38760-50 was selected for the bilateral inguinal lymph
node biopsy procedure. How do you code for the work of the
sentinel lymph node biopsy?
I wanted to select code 38900 - Intraoperative identification
(eg, mapping) of sentinel lymph node(s) includes injection of
non-radioactive dye, when performed (List separately in
addition to code for primary procedure).
This code, however, seems only able to be used with primary
breast surgery procedures.
4
5
Code 38972 (Injection procedure; radioactive tracer for
identification of sentinel node) also does not technically apply,
since the Tc99 injection was performed at the nuclear
medicine department.
Can 58952 be billed with 44970? If so, what modifiers are
required?
A 58954 claim is in hold status because the patient had been
coded with a 57505 the previous week. Is it necessary to add
a modifier to the surgery 58954 code so that it is not
considered "global" with the 57505?
58952 is an open surgery code and 44970 is a laparoscopy code. For an open procedure use 44950 if
incidental appendectomy with -52 modifier or 44955 if indicated appendectomy for tumor.
Appendectomy can only be billed with another open procedure if there is a specific indication, like
secondary cancer or endometriosis. Incidental appendectomies cannot be billed.
A modifier would not normally be used as the global period only includes normal postoperative care - and
it’s pretty clear that a major procedure like 58954 isn’t part of a global for an endocervical curettage.
The answer really depends on how the insurer’s software handles any claim in a global period.
The correct modifier for an unrelated procedure during the global period is 79. Since 57505 has a 10 day
global I would suggest using this modifier for the debulking operation.
Page 21 of 24
SGO Coding and Reimbursement
Questions and Answers by Category
MODIFIER
Question
6
Is there a rule to follow/guidelines regarding the amount of
extra time spent with lysis of adhesions during a surgery in
order to use the 22 modifier?
For instance, the op note indicates that the procedure was
prolonged by over 30 minutes by the exposure of difficulties of
the massive obesity. The procedure is a TLH-BSO.
Answer
There is no specific rule regarding the amount of time and time alone is not sufficient justification for using
this code.
To use this code, documentation of a service significantly greater than typically required is required. It
should include the reason for the additional work, any additional time required, the technical difficulty of
the procedure, or any other rationale why the service required significantly more work.
Even if all requirements are met, enhanced reimbursement is at the discretion of the payor. These claims
usually end up in medical review.
30 minutes additional work might fall into the "some are difficult and some are easy" category. An hour or
more of lysis of adhesions might be worthy of a 22 modifier. There are no published guidelines.
OVARY
Question
Answer
4
How do you report a radical hysterectomy/bso without nodes;
rectosigmoid resection; infragastric omentectomy; and optimal
debulking on a patient with ovarian cancer?
The best approach is to report code 58953 (Bilateral salpingo-oophorectomy with omentectomy, total
abdominal hysterectomy and radical dissection for debulking) plus the appropriate colectomy code
(e.g.44145) or other more appropriate code. If there was also a takedown of the splenic flexure, then you
would also report code 44139 (Mobilization (take-down) of splenic flexure performed in conjunction with
partial colectomy (List separately in addition to primary procedure). Code 44139 is not subject to multiple
procedure reduction since it is an add-on code. The omentectomy is considered part of code 58953 and
thus is not reported separately.
If the hysterectomy was particularly difficult, then modifier 22 can be appended to the primary code.
According to CPT, the documentation must support the substantial additional work and the need for the
additional work.
5
How do you code for a resection of a left ovarian CA; radical
dissection and tumor reduction of pelvic tumor involving the
rectosigmoid, mesentery and left pelvic retroperitoneal
spaces; omentectomy; and pelvic and paraaortic
lymphadenectomy on a patient with Stage III malignant germ
cell tumor? The uterus and right ovary and tube were
preserved.
ACOG, in conjunction with SGO, suggests in its coding manual that code 58954-52 (Bilateral salpingooophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with
pelvic lymphadenectomy and limited para-aortic lymphadenectomy) be reported in this instance. The 52
modifier indicates a "reduced service" since the hysterectomy component was not performed. Not all
payers recognize modifier 52 so that the full allowable amount may be reimbursed for the procedure. You
can choose to decrease your fee as you deem appropriate.
Page 22 of 24
SGO Coding and Reimbursement
Questions and Answers by Category
OVARY
Question
Answer
6
How do you code for ovarian cancer staging for early disease?
We perform a TAH/BSO, pelvic and para-aortic dissection,
omentectomy, and biopsies.
The codes for ovarian cancer procedures are in the 58943-58960 for open procedures. The options for
the above would be code 58951 (Resection (initial) of ovarian, tubal or primary peritoneal malignancy with
bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited
para-aortic lymphadenectomy). If radical dissection for debulking is done, then you would report code
58954 (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical
dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy). Codes
58953-58956 can be used for cancer at all sites including the uterus.
Although the selection of codes for treatment of gyn malignancy is fairly robust, there may be those
occasions when the procedure actually performed is varied slightly from the available codes. In these
instances, you can consider appending either a 52 (reduced services) or 22 (increased services) modifier
to the basic procedure.
7
How do you code for a radical abdominal hysterectomy and an
ovarian suspension?
You should report code 58210 (Radical abdominal hysterectomy, with bilateral total pelvic
lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with
or without removal of ovary(s)) and 58825 (Transposition, ovary(s)).
The CPT instructions beneath code 58210 state "For radical hysterectomy with ovarian transposition, use
also 58825". The term "ovarian suspension" is another way to state "ovarian transposition". You may
need to append modifier 51 (multiple procedure) to 58825.
8
Can you use a BRCA-1 mutation as a diagnosis?
No. There is no specific code for BRCA-1 mutations. Other possibilities include: V84.01-genetic
susceptibility to breast cancer, V84.02-genetic susceptibility to ovarian cancer, or 758.9-conditions due to
anomaly of unspecified chromosome.
9
What code is best to use for an interval ovarian debulking
surgery with TAH-BSO extensive pelvic dissection? There was
no omentectomy or lymphadenectomy. Is it best to use 5815022 (increased procedural services) or 58953? If I used 58953,
would it be necessary to put a 52 reduced services modifier on
it?
Would 58957 be the appropriate code for “total pelvic
peritonectomy, other sites peritonectomy and diaphragmatic
stripping” in ovarian cancer surgery?
If there was described debulking of peritoneal implants, whether or not they turned out to be viable
malignancy, use a debulking code- ie 58953. In the context of extensive debulking without omentectomy, it
is reasonable to not reduce it with a 52. If there was just lysis of adhesions without debulking, then 5815022 or 58956-52.
10
That is probably the best code. 58957 is a code that is used for resection of recurrent gynecologic cancer.
If you are doing a primary debulking then you should use 58952-58954 depending on what else is done.
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SGO Coding and Reimbursement
Questions and Answers by Category
VULVA
Question
Answer
1
How do you code for a partial urethrectomy done en bloc with
a radical vulvectomy for vulvar cancer?
It would be reasonable to report code 53210 (Urethrectomy, total, including cystostomy; female) for the
partial urethrectomy with the reduced services modifier 52. Code 53210 is not bundled into the
vulvectomy codes.
2
How do you code for bilateral inguinal sentinel lymph node
removal performed at the time of radical vulvectomy?
The procedure should be reported using the appropriate vulvectomy code plus code 38500 (Biopsy or
excision of lymph node(s); open, superficial) with the 50 modifier (bilateral procedure). The identification
of the sentinel nodes is reported using code 38792 (Injection procedure for identification of sentinel node)
with the 50 modifier.
3
How do you code for a skinning vulvectomy? Is it better to
report code 56620 or a code from the integumentary section of
CPT?
In general, it is better to be more specific for coding purposes. Codes 56620 and 56625 are specifically
meant for vulvar procedures and should be used instead of integumentary codes.
The 80% rule applies. If you remove >80% of the total vulva, it is considered “Vulvectomy, simple;
complete” (56625). If <80% is removed, it is considered “Vulvectomy, simple; (56620). If a graft is
required, you cannot code for suturing a skin graft into place, as that is considered part of the repair
portion of the vulvectomy codes. If you harvest the skin graft as well, you should use code 15120 (split
thickness autograft, genitalia).
OTHER
Question
1
What is the code for scalpel excision and cauterization of a 2
cm condyloma growing out of the distal urethra?
Answer
You should report code 11422 (Excision, benign lesion including margins, except skin tag (unless listed
elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm). Code selection is
determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for
complete excision (lesion diameter plus the most narrow margins required equals the excised diameter).
Therefore, you should consider this when selecting your code. In the event that the "excised diameter" is
greater than 2 cm, you would report the appropriate code in this family of codes. That would most likely be
code 11423 (excised diameter 2.1 to 3.0 cm).
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