Ob-Gyn Coding Alert

Even though you can report a modifier with 99483, modifier 59 may not be appropriate.

January 1, 2018 has come and gone, so you should already be applying the ob-gyn edits included with the latest round of the Correct Coding Initiative (CCI) version 24.0. If you're staring at a denial involving 38573 or 58575, these edits may be to blame.

Read on to find out what you should know.

Apply These Edits to 38573

Before you start reporting additional codes with 38573 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when performed), you might want to take a moment to consider CCI edits.

You'll find a lot of codes combined with this one - and here's the rub: you can't use a modifier to bypass the bundle. These edits mean that either the additional CPT^® code includes the procedures listed in 38573 or that there exists a combination code in CPT^® that would be billed instead of the two bundled codes, says Melanie Witt, MA, RN, an independent coding expert based in Guadalupita, New Mexico.

The bundled codes include:

• 56640 (Vulvectomy, radical, complete, with inguinofemoral, iliac, and pelvic lymphadenectomy)
• Vaginectomy codes 57109 and 57112
• 57531 (Radical trachelectomy, 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))
• Total abdominal hysterectomy codes 58150, 58152, and 58200
• 58180 (Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s))
• 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))
• 58240 (Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof)
• Supracervical laparoscopic hysterectomy codes 58541, 58542, 58543, and 58544
• 58548 (Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed)
• Surgical laparoscopy with vaginal hysterectomy codes 58550, 58552, 58553, and 58554
• Surgical laparoscopy with total hysterectomy codes 58570, 58571, 58572, and 58573
• Oophorectomy code 58943
• Resection for ovarian, tubal, or primary peritoneal malignancy codes 58950, 58951, and 58952
• Bilateral salpingo-oophorectomy with omentectomy codes 58953, 58954, 58956
• Tumor debulking of recurrent ovarian, tubal, primary peritoneal, uterine malignancy codes 58957 and 58958
• 58960 (Laparotomy, for staging or restaging of ovarian, tubal, or primary peritoneal malignancy (second look), with or without omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diaphragmatic assessment with pelvic and limited para-aortic lymphadenectomy).

New Code 58575 Doesn't Escape CCI's Notice

You also have edits affecting new code 58575 (Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed). You should treat 58575 as a secondary code with the following CPT^® codes:

• Abdominal hysterectomy (58150, 58180, 58200, 58210)
• Vaginal hysterectomy (58262-58263 and 58291-58292)
• Laparoscopic supracervical hysterectomy (58541-58544)
• Laparoscopic radical hysterectomy (58548)
• LAVH (58550-58554)
• Salpingo-oophorectomy (58700, 58720)
• Resection of ovary (58920, 58925)
• Resection for cancer (58943-58958).

Important: You can report modifier 59 (Distinct procedural service) with 58575 to bypass this bundle if the criteria for doing so are met.

In addition, 58575, when billed as the primary code, is bundled with 3,243 CPT^® codes representing a variety of procedures such as integumentary codes relating to debridement (11000-11006 and 11042-+11047), wound repair (12001-12018, 12020-12021, 12031-12057, 13100-+13153), vascular access procedures, anesthesia and like, but also any gynecological CPT^® code that includes any of the elements included in 58575.

More on gyn edits: With the exception of the lysis codes, EUA, and procedures that would always be included when the uterus is removed, you can consider the majority of the gynecological edits allow the use of modifier 59, if the criteria have been met. The procedure ranges for the gyn bundles that would allow a modifier 59 under certain circumstances include:

• Cystoscopy (52000)
• Colpotomy and colpocentesis (57000 and 57020)
• Adjunct procedures performed in the vaginal canal (57100-57452)
• Vaginal, cervical or endometrial biopsies or samplings taken to determine the necessity of the surgery (57500, 57800, 58100)
• Myomectomy (58140-58146, 58545-58546)
• Total abdominal hysterectomy with MMK (58152)
• Vaginal hysterectomy (58260-58294)
• Myomectomy/polypectomy/D&C using hysteroscopy (58558 and 58561)
• Surgery on the fallopian tubes (58670-58673)
• Oophorectomy (58940).

However, you'll find 14 gyn edits with 58575 that never allow you to report a modifier. These include:

• EUA (57410)
• Cervical procedures (57505, 57530, 57550-57555, 57558)
• D&C (58120)
• Total laparoscopic hysterectomy (58570-58573)
• Lysis of adhesions (58660 and 58740)
• Laparoscopic salpingo-oophorectomy (58661)
• Laparoscopic ablation of uterine fibroids (58674).

Modifier 59 May Not Be Appropriate for 99483

You should check out the edits affecting code 99483 (Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements: Cognition-focused evaluation including a pertinent history and examination; Medical decision making of moderate or high complexity; Functional assessment (eg, basic and instrumental activities of daily living), including decision-making capacity; Use of standardized instruments for staging of dementia (eg, functional assessment staging test [FAST], clinical dementia rating [CDR]); Medication reconciliation and review for high-risk medications; Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized screening instrument(s); Evaluation of safety (eg, home), including motor vehicle operation; Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks; Development, updating or revision, or review of an Advance Care Plan; Creation of a written care plan, including initial plans to address any neuropsychiatric symptoms, neuro-cognitive symptoms, functional limitations, and referral to community resources as needed (eg, rehabilitation services, adult day programs, support groups) shared with the patient and/or caregiver with initial education and support. Typically, 50 minutes are spent face-to-face with the patient and/or family or caregiver).

CCI bundles this code into all of the obstetric codes that include any antepartum or postpartum visits (59400/59410, 59425-59426, 59430, 59510/59515, 59610/59614, 59618/59622). CCI has also bundled this code into Q0091, the Medicare collection code for the Pap smear, and G0101, the Medicare covered pelvic examination. You can use an appropriate modifier to bypass this bundling edit if the criteria are met. Keep in mind, however, that since the modifier would need to be placed on 99483, modifier 59 might not be correct.

Highlight These Tumor Removal Code Edits

You will also find new edits for reporting tumor removal codes 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), 49204 (Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5.1-10.0 cm diameter) and 49205 (Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor greater than 10.0 cm diameter).

What's different: Some CPT^® code combinations had previously allowed a modifier to be reported, but now all of these edits have been changed to prevent the use of a modifier and new edits are in place for gyn codes that had not been bundled before, Witt says.

The list of codes which have been permanently bundled into 49203-49205, effective January 1, 2018, are as follows:

• 58920 (Wedge resection or bisection of ovary, unilateral or bilateral)
• 58925 (Ovarian cystectomy, unilateral or bilateral)
• 58940 (Oophorectomy, partial or total, unilateral or bilateral)
• 58943 (... for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingectomy(s), with or without omentectomy)
• 58956 (Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy)
• 58957 (Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed)
• 58958 (Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy)
• 58960 (Laparotomy, for staging or restaging of ovarian, tubal, or primary peritoneal malignancy (second look), with or without omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diaphragmatic assessment with pelvic and limited para-aortic lymphadenectomy).