SGO Coding Frequently Asked Questions (08/02/10)
Category
Question
Answer
1
Chemotherapy
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
Chemotherapy
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
Chemotherapy
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
Chemotherapy
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.
5
Chemotherapy
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
Chemotherapy
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.
Page 1 of 16
SGO Coding Frequently Asked Questions (08/02/10)
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7
Chemotherapy
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
Chemotherapy
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).
9
Brachytherapy
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.
10
Brachytherapy
How do you code for placement of Heyman’s capsules?
Report code 58346 (Insertion of Heyman capsules for clinical brachytherapy).
11
Brachytherapy
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
12
Brachytherapy
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.
Page 2 of 16
SGO Coding Frequently Asked Questions (08/02/10)
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Question
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13
E/M
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.
14
E/M
I heard that SGO suggests that all follow-up visits for cancer
surveillance be reported using code 99214 for up to 5 years?
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 3 of 16
SGO Coding Frequently Asked Questions (08/02/10)
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15
E/M
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.
16
E/M
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 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.
Page 4 of 16
SGO Coding Frequently Asked Questions (08/02/10)
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Question
Answer
17
E/M
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.
18
E/M
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.
19
E/M
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.
20
Endometrial
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.
Page 5 of 16
SGO Coding Frequently Asked Questions (08/02/10)
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21
Endometrial
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.
22
Endometrial
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.
23
General
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.
Page 6 of 16
SGO Coding Frequently Asked Questions (08/02/10)
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24
General
How do you code for a radical hysterectomy when there was not a
node dissection performed because the patient had pre-op 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.
25
General
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. 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.
26
General
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.
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.
27
General
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 Frequently Asked Questions (08/02/10)
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28
General
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.
29
General
What is the most appropriate code for thickened endometrial stripe?
The code is 793.5 (abnormal findings on radiograph, genitourinary).
30
General
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.
31
General
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.
32
General
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.
33
General
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 (Salpingooophorectomy, 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.
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SGO Coding Frequently Asked Questions (08/02/10)
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34
General
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.
35
General
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.
36
General
What code would you report for the removal of 2 large pelvic nodes at
the time of a TAH/BSO on a patient with post-menopausal 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).
37
General
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.
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38
General
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).
39
General
Can ureterolyisis (50715) be reported in addition to code 58150
(TAH/BSO?
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.
40
General
Can management of total parenteral nutrition be reported for a postop 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.
41
Exenteration
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).
42
Exent
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.
43
GI
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).
44
GI
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.
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45
GI
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.
46
GI
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.
47
GI
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.
48
GI
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))
49
Modifier
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.
50
Other
What is the code for scalpel excision and cauterization of a 2 cm
condyloma growing out of the distal urethra?
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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51
Laparoscopy
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, intraabdominal 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.
52
Laparoscopy
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.
53
Laparoscopy
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.
54
Laparoscopy
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. bYou should
make certain that the appropriate ICD code is reported for the procedure.
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55
Laparoscopy
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.
56
Laparoscopy
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-58550-58554 series or TLH58570-58573 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.
57
Laparoscopy
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.
58
Laparoscopy
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.
59
Laparoscopy
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.
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Laparoscopy
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.
61
Cervix
How do you code for a radical parametrectomy?
Report a code from the series 57107-57111 (vaginectomy with removal of
paravaginal tissue)
62
Cervix
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.
63
Cervix
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).
64
Ovarian
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.
65
Ovary
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 salpingo-oophorectomy with omentectomy, total abdominal hysterectomy
and radical dissection for debulking; with pelvic lymphadenectomy and limited paraaortic 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.
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66
Ovary
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.
67
Ovary
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.
68
Ovary
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.
69
Vulva
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.
70
Vulva
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.
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Vulva
Question
Answer
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).
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