Ob-Gyn Coding Alert

Challenge: Take what you-ve learned and tackle this second scenario

Coding op notes doesn't have to overwhelm you if you can order your coding choices, spot bundled codes, and pinpoint necessary modifiers.

 Break down this example into five simple steps, and you-ll steer clear of reimbursement complications

 Op note example: Your ob-gyn did a surgery using a laparoscopic approach. His documentation states, -Pre-op diagnosis: Painful left ovarian cyst. Procedures in order performed (two auxiliary ports):

 1. Left ovarian cystectomy
 2. Sharp dissection of dense adhesions from sigmoid to left adnexa and posterior uterus involving 1 hour of additional time to remove
 3. Destruction of endometriosis left pelvic sidewall, vesicouterine reflection, and posterior cul-de-sac.-

Step 1: Rank Codes in RVU Order

 First, you should identify all the procedures your ob-gyn performed by allotting them a code. Place these codes in order of their relative value units (RVUs), listing the highest value code first. Don't forget to append the appropriate modifier to all subsequent procedures unless they are represented by add-on codes, says Rebecca Lopez, CPC, certified coder at Bright Health Physicians in Whittier, Calif.

 For the left laparoscopic cystectomy, you would report 58661 (Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]) if the ob-gyn removed part of the ovary along with the cyst. If the ob-gyn removed the cyst intact, you would report 58662 (... with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method) for both the cyst and the destruction of the endometriosis.

 As for the lysis of adhesions part of this procedure, you would report 58660(... with lysis of adhesions [salpingolysis, ovariolysis] [separate procedure]).

So that's 58661, 58662, and 58660, or possibly just 58662 and 58660. According to the RVU scale, the code 58662 has more work RVUs (12.08) than 58661 (11.30), so you should report that code first.

Step 2: Eliminate Surgical Standards

Review your list of codes. Identify and eliminate those codes that are surgical standards (such as those for exploratory laparotomy, diagnostic laparoscopy, diagnostic hysteroscopy, exam under anesthesia, surgical access, integral procedures, hemostasis control, drain placement, a procedure checking the surgeon's work, and so on). You shouldn't list codes for these inherent services when performed with other surgical procedures.

Impact: You shouldn't report 58660 in the previous surgical scenario because this code is a -separate procedure.- CPT considers this an integral component of some larger procedure Therefore, you shouldn't report it in addition to the code for the total procedure.

Step 3: Note Any CCI Edits

 Check the Correct Coding Initiative (CCI) for coding edits. Note: You can see the edits online at www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp. Eliminate code combinations CCI won't allow (such as lysis of adhesions).

 If you look at CCI, you-ll see that both 58662 and 58661 aren't bundled. But CCI bundles 58660 into both 58662 and 58661, which means this code does not belong on your claim.

Step 4: Add Modifier 22 for Extra Work

Add modifier 22 (Increased procedural services) to the primary code if the surgical report indicates that your ob-gyn did significant extra work for bundled codes.

For example, modifier 22 is the only way to get Medicare to pay attention to the work for lysis of adhesions because CCI permanently bundles lysis into many codes and you cannot use a modifier to bypass this edit. Using modifier 22 puts the claim into manual review. If your documentation supports the extra significant work, Medicare may pay for the lysis or the bundled code.

If you-ve got the appropriate documentation supporting additional work, you should add modifier 22 to 58662.

Step 5: Mull Over Other Modifiers

 Look for places where you can appropriately append a modifier. For example, if your documentation meets the criteria for reporting procedures bundled by CCI, you should add the appropriate modifier assigned by the payer to bypass the edit.
 For Medicare, these would be:
 - modifier 59 (Distinct procedural service)
 - modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) 
 modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), or
 - modifiers RT (Right side) or LT (Left side).

Annette Grady, CPC, CPC-H, CPC-P, CCS-P, compliance auditor at The Coding Network and executive officer on the AAPC's National Advisory Board, outlines these modifiers in the audioconference entitled -Under the Magnifying Glass: A

Closer Look at Mitigating Modifier Mishaps.- Note: To order your transcript and audio conference materials, go to www.audioeducator.com.

 In the above scenario, you should add modifier 51 (Multiple procedures) to 58661 if the ob-gyn removed part of the ovary along with the cyst, because you-ll report the primary procedure (58662) for the removal of the endometriosis. 

 Result: If your ob-gyn performed both types of removal in the surgical scenario, you-ll report 58662-22 and 58661-51 for this procedure. If the ob-gyn removed no part of the ovary along with the cyst, you-ll just report 58662-22.

Try Your Hand at This Second Scenario

You receive the following report for this surgery ��" again, a laparoscopic procedure. The documentation states, -Pre-op diagnosis: enlarging 6-cm septated left ovarian cyst, dysmenorrhea with very heavy

flow,stenotic cervix.

1. Hysteroscopy with D&C returning a large amount of polypoid endometrium

2. Laparoscopy with cystotomy of large left corpus luteum cyst, and excision of paratubal chocolate cyst

3. Destruction of endometrial implants on vesicouterine reflection, uterosacral ligaments (bilaterally), cul-de-sac, and right utero-ovarian ligament.-

 Note: The path report has the chocolate cyst labeled as -right salpingo cyst,- but the dictation of your ob-gyn's report is such that it seems the chocolate cyst was paratubal and proximal on the left. This is why it's important to recognize your ob-gyn's language. Don't be afraid to ask him to clarify anything you don't understand.

Step 1: For the hysteroscopy with D&C, you-ll report 58558 (Hysteroscopy, surgical; with sampling [biopsy] of endometrium and/or polypectomy, with or without D&C).

 For the laparoscopic removal of the cysts from tube and ovary, you should report 58662. This code includes the laparoscopic removal of endometriosis as well. 

 That's 58558 and 58662. Code 58662 has 12.08 work RVUs, so you should list it first. Code 58558 has only 4.74 work RVUs.

 Step 2: None of the procedures are standards of surgical practice

 Step 3: These two codes are not bundled, according to CCI

 Step 4: If you can show extensive work and time added to the surgery for the removal of the cysts plus endometriosis, you might possibly append modifier 22 to 58662

 Step 5: You don't have any CCI edits to contend with in this procedure, so you don't need to worry about additional modifiers. If the ob-gyn removed part of the ovary along with the cyst (discussed in the first example), however, you might be able to report 58661-51 in addition. 

Result: Report 58662-22 and 58558-51, or possibly 58662, 58661-51, and 58558-51.