Ob-Gyn Coding Alert

Here’s how to potentially add $208 to your bottom line.

When an ovarian cyst removal claim lands on your desk, you should pay particular attention to the approach — whether it is vaginal, abdominal (open), or laparoscopic. Following tips like this means that you can obliterate ovarian cyst removal mistakes.

For Laparoscopic Cysts, Look to Extent of Procedure

Myth #1: If your ob-gyn documents that he removed an ovarian cyst via a laparoscope, then you have all you need to choose what code to report.

Reality: For a laparoscopic removal of an ovarian cyst, you’ve got to dig deeper into your ob-gyn’s documentation and select the code based on the procedure’s extent:

When a laparoscopic ovarian cyst excision does not involve the removal of any additional ovarian tissue, the correct procedure code is 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method).

When the cyst is large and difficult to remove, the ob-gyn may have to remove part of the ovary at the same time. You should report this using 58661 (Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]).

Pitfall: If you look only at the CPT^® index under “cystectomy, ovarian, laparoscopic” you may be coding incorrectly, says Melanie Witt, RN, CPC, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M. CPT^® indicates that 58661 is the code you should use, but the surgeon’s documentation is the determining factor.

Coding based on documentation alone can cost you $58. “The removal of an ovarian cyst is more work than removing the ovary,” Witt says. Because a cyst removal involves more careful dissection, 58662 have more relative value units (RVUs) than 58661.

Good idea: Always make sure to read your op note carefully, as sometimes the ob-gyn does more than what is noted under the summary. Also be sure to read the path report which will also indicate whether there was part of an ovary in the sample.

Get Your Documentation Up to Snuff

Myth #2: Your ob-gyn performs an ovarian cystectomy for an asymptomatic benign ovarian cyst in a non-pregnant woman of reproductive age. Because coding for the cyst is so straightforward, the ob-gyn doesn’t need much documentation to support the claim.

Reality: Coding for the cyst removal may be straightforward, but you need to make sure your documentation meets medical necessity. The American Congress of Obstetricians and Gynecologists (ACOG) have outlined the following steps to ensure proper documentation.

The ob-gyn should document the following in the patient’s medical record:

1. Last menstrual period and contraceptive method and one or more of the following:

    a) Pelvic examination or ultrasound demonstrating a cystic mass that is 8 cm or larger

    b)     Persistence of a cystic mass of 6 cm or larger for two cycles

    c) Presence of a cystic mass that is multilocular (many-celled) or has solid components, as confirmed by ultrasound.

2. Pelvic examination in the operating room or within 24 hours prior to the procedure to confirm persistence or presence of mass.

Treat Cyst Aspiration and Drainage the Same

Myth #3: If your ob-gyn documents an “aspiration” or “drainage” of an ovarian cyst, you should treat these services differently.

Reality: To “aspirate” an ovarian cyst means that the ob-gyn removes fluids using a suction device, but the terms “aspiration” and “drainage” are synonymous in this case. The code you choose depends on the method the physician uses to perform the aspiration:

·         If the ob-gyn aspirates ovarian cysts through an incision in the vaginal canal, you should report 58800 (Drainage of ovarian cyst[s], unilateral or bilateral [separate procedure]; vaginal approach).

·         If the ob-gyn aspirates through an abdominal incision, use 58805 (... abdominal approach).

·         If he performs laparoscopic aspiration, report 49322 (Laparoscopy, surgical; with aspiration of cavity or cyst [e.g., ovarian cyst] [single or multiple]), Witt says.

Give U/S Guidance Its Own Code

Myth #4: Your ob-gyn may need to use guidance when he must aspirate the cyst blindly through the skin or vaginal incision, but you should consider that inherent to the aspiration service.

Reality: If the ob-gyn uses ultrasound guidance to place the needle that he uses to aspirate the cyst through the vaginal approach, you’ll also likely get to report 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation). That’s in addition to 58800. Keep in mind that 76942 reimburses about $208. If the ob-gyn removes the cyst in the hospital, however, then you would report 76942-26 (Professional component), which reimburses only $32.