Ob-Gyn Coding Alert

Don’t assume number of biopsy units matches number of samples.

Are you sure you’re getting the reimbursement your ob-gyn deserves for biopsy procedures? Take this quiz and avoid the many pitfalls of biopsy coding and billing.

Background: A biopsy is a tissue sample that the ob-gyn excises from the patient to ascertain the presence of cancer. Ob-gyns will most likely perform biopsies of the vulva, cervix, vagina, endometrium, and ovary(s). Ob-gyns usually order a biopsy due to abnormal vaginal bleeding or after the detection of a mass, cyst, lump, tumor or cells of abnormal appearance.

Best bet: You should code all your biopsies with the copy of the pathology report to back up your diagnoses. Make this a rule when you’re coding biopsies, and your claim is sure to sail.

Scenario 1: Lap-to-Open Biopsy Procedure

The ob-gyn performs an ovarian biopsy laparoscopically on the left side. The biopsy reveals malignancy, so the ob-gyn converts to an open procedure to remove the ovary(s). What should you report?

Solution: The code for a laparoscopic ovarian biopsy is 49321 (Laparoscopy, surgical; with biopsy [single or multiple]). If the intraoperative biopsy reveals malignancy, the ob-gyn may convert to an open procedure to remove the ovary(s) (for example, 58940, Oophorectomy, partial or total, unilateral or bilateral).

Note: You cannot report 58950 (Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy) even though the results came back as a malignancy, because the ob-gyn did not perform an omentectomy.

At this point, most payers will consider the biopsy part of the more extensive procedure, but some may reimburse 49321 separately, especially if future surgery was contingent on the biopsy result (i.e., the patient was not originally scheduled for a bilateral salpingo-oophorectomy [BSO]). If the work involved in performing the laparoscopy and obtaining the biopsy was significant and well documented, you may use modifier 22 (Increased procedural services) appended onto 58940 (Oophorectomy, partial or total, unilateral or bilateral) to obtain higher reimbursement. Your payer will decide if it wants it billed separately or if it wants the extensive procedure with modifier 22 option.

Don’t forget: If the ovarian biopsy revealed malignancy, you’ll likely attach a diagnosis like malignant ovarian neoplasm (C56.2, Malignant neoplasm of left ovary) for 58940. Be careful though. You should never report a code for malignancy because the ob-gyn states it looks malignant without pathology confirming it.

Scenario 2: Look for These Additional Coding Opportunities

A patient with irregular intermenstrual bleeding (N92.1, Excessive and frequent menstruation with irregular cycle) undergoes an office procedure in which the ob-gyn extracts samples from the tissue lining the inside of the uterus (endometrium). They insert a plastic catheter into the uterus and suction out a small amount of the endometrial lining. What should you report?

Solution: This is an endometrial biopsy, so you should report 58100 (Endometrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, any method [separate procedure]). This code represents a fairly straightforward procedure that an ob-gyn does in the office, without general or local anesthesia in most cases.

Keep in mind: You can report 58100 with a preventive or problem-oriented E/M visit by attaching modifier 25 (Significant, separately identifiable Evaluation and Management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code if the ob-gyn documented a separate, significant E/M service. If the patient reports for a biopsy and the ob-gyn planned or conducted no other service, however, you should report the biopsy code on its own.

Also, if your ob-gyn performs an endometrial biopsy in addition to a colposcopy, you should use the add-on code +58110 (Endometrial sampling [biopsy] performed in conjunction with colposcopy [list separately in addition to code for primary procedure]) for the biopsy instead of 58100.

Scenario 3: Count Lesions Carefully