Download archived coding questions and answers

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
Gastro-intestinal
ICD-10
Laparoscopy
Lymph Nodes
Modifier
Ovary
Vulva
Other
If you do not find the answer to your question here, please send an email to [email protected]. Members of the SGO Coding and Reimbursement Taskforce alternate reviewing
incoming inquiries and providing recommendations.
Page 1 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
BRACHYTHERAPY
1
How do you code for the insertion of a Smit/cervical sleeve?
The SGO coding committee suggests that the insertion of the Smit 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 The surgeon should use code 57155 (insertion of uterine tandems and/or vaginal ovoids for clinical
Dose Rate (HDR) brachytherapy?
brachytherapy) for insertion of tandem and ovoid. If a tandem is not placed, use a reduced service
modifier 52.
5
How does one bill for placement of fiducial markers/seed markers at the time of placement of a cervical/Smit sleeve for
brachytherapy?
Use 57800, add -22 modifier.
This will require a copy of the procedure note to obtain additional reimbursement.
CERVIX
6
How do you code for a radical parametrectomy?
Report a code from the series 57107-57111 (vaginectomy with removal of paravaginal tissue)
7
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.
8
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).
Page 2 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
CHEMOTHERAPY
9
We currently use Z58.11 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 Z51.11 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 Z51.11 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.
10
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 Z71.89 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.
11
Do we still use 96446 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
96446 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.
12
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 Z51.11 is specifically for the encounter at which chemotherapy is being provided.
13
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.
14
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 3 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
15
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.
16
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-10 code for counseling, such as Z71.89 (other specific counseling).
17
The physicians are currently on the hospital floor when the
chemo is being administered by the nursing staff at the hospital
and want to start billing for chemo administration. I was asked
to look into billing and I have not been able to find anything that
would allow us to bill at a hospital if the nursing staff is employed by a different employer than the providers. Can you
please clarify under what conditions providers can bill for
chemo in a hospital setting?
Chemo administration codes require that the staff are your employees giving the chemo in your facility.
If the doctor sees the patient at the hospital on the day of the chemo they could bill the appropriate E&M
code but could not bill for the administration (i.e. 96365-96379 or 96401-96549). Chemotherapy administration codes reimburse primarily for the overhead/personnel costs of the infusion center.
You can only bill for chemotherapy administration if you own the facility. If it is a hospital–based infusion
center, you cannot collect for chemo administration. However, the amount of physician work associated
with most chemo admin codes is about 0.5 RVUs.
You can charge for E&M codes if they are separately identifiable services. You then must document
what was done and show medical justification for the visit. It should not be duplicative of clinic visits.
EVALUATION AND MANAGEMENT
18
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.
Page 4 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
19
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.“
20
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.
Page 5 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
21
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.
22
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.
23
How long can you use the cancer diagnosis (C56.1-9) 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 C56.1-9 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, Z85.43 -ovarian cancer, personal history). Either choice is acceptable and both codes appear to be covered by the majority
of payors.
Page 6 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
24
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?
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.
25
Can you bill an E&M code for a visit after surgery during the
global time period to discuss chemotherapy or radiation (i.e. a
“counseling” session).
CMS specifically addresses what can and cannot be billed during the global period here:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf
You can bill for E&M codes if they are distinct from the surgical care, clearly documented, and have the
modifier “-24” (Unrelated E/M service by the same physician during a post-operative period). The physician may need to indicate that an E/M service was furnished during the postoperative period of an unrelated procedure. An E/M service billed with modifier “-24” must be accompanied by documentation that
supports that the service is not related to the postoperative care of the procedure.
One issue is that we usually link a cancer ICD-10 code with both the preoperative diagnosis and the
cancer counseling. The “counseling and coordination of care” code, Z71.89, can be used before reporting the cancer code to avoid this issue. That said, not all insurers will pay for this service.
26
When deciding on the level of Medical Decision Making complexity, can the MDM be a high level if the physician discusses
high risk surgery with many other options but the patient declines the surgery?
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. The medical decision was performed and the patient made a decision based on it.
27
How often may a colposcopy be performed during surveillance?
There is no rule on use or frequency of allowed colposcopy visits. However, you could use clinical criteria for surveillance. Colposcopy is typically indicated for evaluation of abnormal pap smears.
Page 7 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
28
What is the proper code for surveillance visit? I have used
99214 moderate complexity or 99213 low complexity.
The level of billing of E&M services is determined by the extent of the history, review of systems, and
physical examination. Level 3 established patient visits typically require decision making of low complexity while level 4 visits require moderate complexity decision making. The level of decision making is
based on the problems addressed, the data reviewed, and the level of risk. Surveillance of a treated malignancy with some risk of recurrence is typically considered of moderate complexity and justifies a level
4 billing. For patients with a remote history of cancer (ie > 5 years disease-free) are typically at low risk
of recurrence and would more appropriately be billed at level 3.
29
What are 4 HPI elements can be used as examples for documentation on ovarian cancer?
Stage 3C ovarian cancer diagnosed 3 years ago, treated with surgery and chemotherapy. No current
pain or bowel symptoms.
You may use symptoms, duration, severity, associated elements:
For example” Patient had bloating and abdominal pain for 1 month, which was moderately severe and
associated with constipation and anorexia. Enemas relieved some of the pain and bloating.”
ENDOMETRIAL
30
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.
31
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-10 D48.3 Neoplasm of uncertain behavior of retroperitoneum or
D48.4 Neoplasm of uncertain behavior of peritoneum, 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.
Page 8 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
32
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-10 code that
justifies the procedure (i.e., C78.6, secondary malignant neoplasm of retroperitoneum and peritoneum).
Medicare will never reimburse for an omentectomy done at the time of a hysterectomy but other payors
might under this circumstance.
33
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."
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 ICD10 code is Z30.430. 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.
34
How do you code for IUD placement for endometrial hyperplasia or cancer, not for contraceptive purposes?
35
What is the code for laparoscopic or robotic endometrial cancer You would code the hysterectomy (58571) and LN separately (38572-51)?If the uterus was > 250gm
surgery with hysterectomy+BSO with pelvic and para-aortic
then 58573 should be used, and laparoscopic pelvic lymph node resection only is 38751
lymphadenectomy?
36
When should the “history of” code be used on follow up of patients with endometrial cancers? When should Z08 and
Z48.816 be used in the postoperative visits?
There is controversy as to when a cancer becomes a “history of”. We recommend using the 5 years
mark as recurrences are rare after that time. Z08 is used exclusively in the global postoperative period.
After the 90 days global period, Z48.816 is used for billable encounter for surgical aftercare.
Page 9 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
EXENTERATION
37
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).
38
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.
39
How would you code a total pelvic exenteration if a colorectal
surgeon performs the colon resection?
The code for total pelvic exenteration is58240and you would append a -52 modifier for the reduced services. The colorectal surgeon should charge for their procedure.
You can also bill for an omental flap with the code 49905.
GASTRO-INTESTINAL
40
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).
41
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.
42
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.
43
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.
Page 10 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
44
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.
45
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))
46
Can 58952 be billed with 44970? If so, what modifiers are required?
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.
ICD-10
47
Is Z08 only used in the global period?
Correct! It is used exclusively in the global period. Z08 (and Z09) are used in encounters for follow-up
examination after completed treatment for malignant neoplasm (and conditions other than malignant neoplasm). These ICD-10-CM codes are used to replace ICD-9-CM codes V67.00 (and V67.09).
48
When is Z51.89 used?
It is used for encounter for other specified aftercare. We recommend using it in the period after the completion of chemotherapy, but before you are ready to declare a “history of.” A secondary diagnosis which
is the active cancer code is required.
49
When is it appropriate to use Z12.4 or Z12.72?
Z12.4 or Z12.72 are used for a routine screening for malignant neoplasm of cervix. I can’t think of any
occasion where it would be appropriate to use for a patient who had a cancer diagnosis, until they have
passed the 5 year mark—even then, I would use the “history of” code, unless the payer won’t pay with
that diagnosis. Z12.4 is used when a Pap is done for unexplained post-coital bleeding. Pap smear obtained with a general exam should be coded Z01.4- . Z12.72 would be used for a Pap obtained for a
post-hysterectomy patient with a history of HGSIL (CIN2-3). If they have a history of invasive cervical
cancer (C53.9), Z08 should be used.
50
What is the encounter code used in follow up of patients during
and after receiving chemotherapy or radiation therapy?
It would be the active cancer code or Z51.89 with the active cancer code secondary.
51
Do we need to add the acquired absence of organ (Z90.710) to
each visit?
It is not necessary on a routine basis unless it is clinically relevant to a particular encounter.
52
Which is the best encounter code used on follow up of patients
to ensure that we will receive payment?
We recommend using Z51.89 with the active cancer code, or just the active cancer code.
Page 11 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
53
How do you code for ovarian cancer with cancers in both ovaries?
ICD10 offers option of laterality for ovarian cancer. In case the physician can specify right or left we
should be specific. In case that it is unclear, we will use C56.9 which is unspecified.
If the patient has bilateral involvement by ovarian cancer, C56.9 (unspecified laterality) would be the
most appropriate code in ICD10.
54
Is using unspecified codes such as C56.9 (Malignant neoplasm
of unspecified ovary), C53.9 (Malignant neoplasm of cervix
uteri, unspecified), and C54.9 (Malignant neoplasm of corpus
uteri, unspecified) acceptable to Medicare and other insurance
carriers?
Non-specific codes should be avoided as much as possible. It shouldn’t be that difficult to convert to a
more specific code for endometrial and cervix once surgery and/or pathology results are available.
Squamous carcinomas which are typically exocervix C53.1 and adenocarcinomas are usually endocervix C53.0 and endometrial is C54.1. For ovarian cancer, CT or US and the presence of a mass should
help in determining side of involvement C56.1 right, C56.2 left if no surgery performed. It is a good practice to convert nonspecific codes to more specific values prior to billing.
55
Is it always necessary to identify the sites of advanced ovarian
or fallopian tube cancer in ICD-10?
Yes it is required for ICD-10 to identify right, left or unidentified site of the primary tumors. Here are the
ICD-10 codes for ovarian cancer:
C56 Malignant neoplasm of ovary (primary)
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
C56.9 Malignant neoplasm of unspecified ovary
C79.6 Secondary malignant neoplasm of ovary
C79.60 Secondary malignant neoplasm of unspecified ovary
C79.61 Secondary malignant neoplasm of right ovary
C79.62 Secondary malignant neoplasm of left ovary
D39.1 Neoplasm of uncertain behavior of ovary (borderline neoplasm)
D39.10 Neoplasm of uncertain behavior of unspecified ovary
D39.11 Neoplasm of uncertain behavior of right ovary
D39.12 Neoplasm of uncertain behavior of left ovary
Stage does not matter when using ICD 10 coding, other than using the laterality codes. These codes
include all stages.
56
How do you code for borderline ovarian tumors or tumors of
low malignant potential? Should histology types (ie mucinous)
be included in the coding?
Borderline ovarian tumors are not cancer, they are coded differently from ovarian cancer:
D39.1 Neoplasm of uncertain behavior of ovary
D39.10 Neoplasm of uncertain behavior of unspecified ovary
D39.11 Neoplasm of uncertain behavior of right ovary
D39.12 Neoplasm of uncertain behavior of left ovary
If it’s ovarian cancer, then these are the codes:
C56 Malignant neoplasm of ovary
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
Page 12 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
C56.9 Malignant neoplasm of unspecified ovary
Histological types such as mucinous tumors are not included in ICD-10 codes. However, they are included in the ICD-Oncology codes. By and large, these are not needed for medical coding, but are important for tumor registries.
57
There seems to be much debate regarding Z codes versus
cancer diagnosis codes. It has even been suggested that we
use Z 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-10 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.
LAPAROSCOPY
58
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.
59
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 13 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
60
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.
61
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.
62
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.
63
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.
64
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.
Page 14 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
65
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.
66
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.
67
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 58661for 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.
68
How do you code for robotically-assisted total laparoscopic
Use 58571/3 with 38572 and the unlisted laparoscopic code for omentectomy and use the RVUs and
hysterectomy, bilateral salpingo-oophorectomy, pelvic and aor- charges for an open omentectomy.
tic lymph node dissection, omentectomy and multiple peritoneal
biopsies?
69
Regarding billing for a gelport robotic assisted salpingo-oopho- The op-report should dictate the billing. Robotics is not billed any different than laparoscopy. Based on
rectomy; as this type of equipment requires a larger incision
the fact that a robotic USO was done, it is recommended to submit a 58661 with a 22 modifier and subthan other types of laparoscopy, can this procedure be billed as mit the op report with it. It is not recommended to code this as an open procedure.
“open” vs “laparoscopic” CPT code?
70
What code should be used to report a vaginal incision or “episiotomy” after Robotic Hysterectomy?
If using code 58548, is it okay to bill for the incision to remove
the uterus?
Not separately billable. It is necessary to perform the planned procedure and is not billable.
Unless the incision or repair was done for a separate indication or diagnosis, it won’t be billable as part
of 58548.
Page 15 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
71
How should laparoscopic uretrolysis (CPT 50949) coded as a
bilateral procedure and be paid as a bilateral procedure?
The unlisted codes (ie CPT 50949) are always problematic but be sure to use the -50 modifier if you
hope to get paid for bilateral procedures.
72
What is the best CPT code for laparoscopic ureterolysis performed during a difficult laparoscopic hysterectomy (CPT code
58571)?
The best way to code for a difficult laparoscopic hysterectomy with BSO is to add a -22 modifier with the
58571 code.
73
Should TLH/BSO/pelvic & PA nodes performed for endometrial
cancer be billed as 58548 or billing separately as 38573 and
58571?
58548 is the code for a type 2 or 3 radical hysterectomy done laparoscopically for cervical or stage 2
endometrial cancer. A laparoscopic hysterectomy/BSO/ pelvic and para-aortic node lymphadenectomy/biopsy should be billed as 58571 with 38572-59.
LYMPH NODES
74
How do I code a robotic parametrectomy with lymph node dissection?
Use laparoscopic radical hysterectomy code (58548) with a -52 modifier for reduced work. You will have
to provide documentation to explain.
Alternatively, you could submit code 38571 plus the unlisted laparoscopic/robotic procedure code. You
will also have to submit documentation to explain. And while this is the most accurate description, at
times, unlisted codes are hard to get reimbursed.
75
How do you code for laparoscopic/robotic sentinel lymph node
biopsy(ies) in endometrial and cervical carcinoma?
If done with a hysterectomy, use the code to the hysterectomy plus the code for lymph node sampling
and mapping.
Laparoscopic hysterectomy +/- BSO = 58571 (uterus <250gm) or 58572 (uterus >250gm)
Lymph node mapping (injection of non-radioactive dye) = 38900
38570 = retroperitoneal node sampling (this would apply to a situation where only a few isolated nodes
were removed. i.e. setinel lymph nodes)
Page 16 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
76
How do you determine the difference between node sampling,
biopsy, dissection and lymphadenectomy?
"Node dissection" and "lymphadenectomy" are often used interchangeably and usually this means that
the entire nodal bundles are removed rather than a few isolated nodes.
For open procedures, options are:
38562 - Limited lymphadenectomy for staging; pelvic and para-aortic. This would be appropriate for a
situation in which only a few selected nodes were removed without performing a full lymphadenectomy.
i.e. sentinel lymph node(s) or isolated enlarged lymph nodes.
38770 - Pelvic lymphadenectomy including external iliac and obturator nodes.
38780 - Retroperitoneal lymphadenectomy, extensive. Includes pelvic and paraaortic and infrarenal
nodes
For laparoscopic procedures:
38570 - Retroperitoneal lymph node sampling. (This would apply to a situation where only a few isolated
nodes are removed. i.e. sentinel lymph node(s) or isolated enlarged node(s)
38571 - Total pelvic lymphadenectomy
38572 - Total pelvic lymphadenectomy with paraaortic node sampling
77
How should I code for a robotic total laparoscopic hysterectomy Codes I would recommend for various robotic procedures for endometrial cancer are
with bilateral salpingoophorectomy and sentinel lymph node
mapping with removal of a right and left external iliac sentinel
Robotic hyst/bso/bilateral pelvic lymphadenectomy
lymph node?
58571; 38571
Robotic hyst/bso/bilateral pelvic lymphadenectomy/aortic node sampling
58571; 38572
Robotic hyst/bso/bilateral sentinel lymph node biopsies
58571; 38570; 38900 (when sentinel node biopsy technique was used)
There are no specific CPT codes for robotic surgery for endometrial or ovarian cancers.
If you inject the radioactive tracer then you can also bill the 38792 but if nuclear medicine does it then
they bill that code
MODIFIER
Page 17 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
78
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?
79
For open hysterectomy on an obese patient with a 24 week
A -22 modifier could be used if the procedure is more extensive than normal if the additional time and
uterus and a 30cm incision, can we be reimbursed for the clowork involved is documented. A separate code for closure is not billable in this circumstance.
sure/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 1300013102.
80
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.
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.
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.
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.
Page 18 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
81
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?
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.
82
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.
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
83
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.
84
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 19 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
85
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.
86
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.
87
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 Q99.9-conditions due to
anomaly of unspecified chromosome.
88
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 58150-22
(increased procedural services) or 58953? If I used 58953,
would it be necessary to put a 52 reduced services modifier on
it?
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
58150-22 or 58956-52.
89
Would 58957 be the appropriate code for “total pelvic peritonectomy, other sites peritonectomy and diaphragmatic stripping” in ovarian cancer surgery?
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.
90
Can I use 49205 for removing a large (>10cm) ovarian mass
through a laparotomy incision?
49205 is not to be used in this circumstance. The procedure described is an oophorectomy and the
code 58720 is the same if large, medium or small oophorectomy.
Page 20 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
VULVA
91
How do you code for a partial urethrectomy done en bloc with a It would be reasonable to report code 53210 (Urethrectomy, total, including cystostomy; female) for the
radical vulvectomy for vulvar cancer?
partial urethrectomy with the reduced services modifier 52. Code 53210 is not bundled into the vulvectomy codes.
92
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.
93
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).
94
What is the most appropriate code for extramammary vulvar
Paget’s disease?
D07.1 is the ICD 10 code for vulvar carcinoma in situ. The code does not specify the histologic type
(squamous vs adeno). This is the most appropriate code for vulvar Paget’s disease ie adenocarcinoma
in situ of the vulva. If there is invasion then the appropriate codes would be from the C51 series (Vulvar
carcinoma, again without distinction for histologic subtype). There are 5 codes to choose from depending on the anatomic location of the primary tumor.
OTHER
95
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).
Page 21 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
96
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.
97
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.
98
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.
99
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.
100
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.
Page 22 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
101
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.
102
What is the most appropriate code for thickened endometrial
stripe?
The code is R93.8 (abnormal findings on radiograph, genitourinary).
103
Is it appropriate to use code C7A.098 (Malignant carcinoid tumor of other sites) for Vipoma?
A true VIPoma is a tumor of the endocrine pancreas cells. Code C7A.098 would not be appropriate.
Code C7A.098 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.
104
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.
105
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.
106
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 23 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
107
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.
108
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.
109
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).
110
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.
111
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 24 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
112
Can ureterolyisis (50715) be reported in addition to code 58150 Code 50715 is a code used to manage ureteral obstruction secondary to retroperitoneal fibrosis. Ab(TAH/BSO?
sent 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.
113
114
115
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.
Physician performed a fiducial marker of the vagina. She didn’t 57410, examination under anesthesia.
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?
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.
116
Is it possible to bill for 99360 as “back up” for surgeries?
When standby care is requested, both the requesting physician and providing physician must document
the need for standby care. The standby doctor must not provide care to other patients during the
standby period. Sitting in the office or doctors’ lounge waiting on a call probably doesn’t qualify as “back
up”. Documentation such as noted below might be useful.
I was requested by [DOCTOR’S NAME] to be on standby for [PROCEDURE/INDICATION] performed
on [PATIENT’S NAME] on [DATE]. I arrived at the operating room at [ARRIVAL TIME] and departed at
[DEPARTURE TIME]. –
Page 25 of 26
SGO Coding and Reimbursement
Questions and Answers by Category
117
When should the “history of” code (V10.41) be used on following of a patient with gynecologic cancer?
It is reasonable to use the diagnosis code for the primary malignancy in the first 5 years after diagnosis.
During this time 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 a patient is no longer receiving
treatment for a specific disease a personal history code is appropriate to use. There should be no issues with reimbursement for these codes.
You could use the malignancy code for 5 years after diagnosis, or 5 years after the last known active
cancer. So, for example:
Endometrial cancer diagnosed 2010 – would use the 182.0 code until 2015.
Endometrial cancer diagnosed 2010 with vaginal cuff recurrence 2012 treated with radiation – would
use the 182.0 code until 2017.
If the patient has been without evidence of disease for 5 years then use the personal history codes.
118
What code is best to use when you have an interval debulking
surgery with TAH-BSO extensive pelvic dissection. There was
no omentectomy or lymphadenectomy performed. This surgery
is for ovarian cancer. All of the malignancy codes include an
omentectomy.
First, interval debulking surgery would be treated like primary surgery for coding purposes. If there was
described debulking of peritoneal implants, whether or not they turned out to be viable malignancy- or
old, dead areas of carcinomatosis, CPT 58953 (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking) would be the most appropriate. The 52 modifier would be added if there were significant reductions in services and can lead to up to 50%
reductions in payments. I would contact the insurer prior to submitting the -52 modifier to see their company policies.
Page 26 of 26