Ob-Gyn Coding Alert

NCCI 28.0:

Hesitate Before Reporting Lymphadenectomy, Hysterectomy Multi-Procedure Claims — Here’s Why

Beware: Pay attention to the modifier indicators.

If your New Year’s resolution is to avoid claim denials, then you should pay attention to the latest round of National Correct Coding Initiative (NCCI) edits. NCCI version 28.0 went into effect Jan. 1, 2022, so that means you should implement these changes if you haven’t already.

Here’s the good news though: We’ve sifted through the 46,574 procedure-to-procedure (PTP) edit pairs and 210 new medically unlikely edits (MUE) to give your ob-gyn practice what it needs to be successful in 2022.

Read on to learn about the new changes affecting lymphadenectomy, hysterectomy, and intradermal cancer immunotherapy procedures.

New Edits Target Lymphadenectomy Code 38765

You should think twice before reporting 38765 (Inguinofemoral lymphadenectomy, superficial, in continuity with pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure)).

The reason is that NCCI bundles this code into the following procedures:

  • 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))
  • 58953 (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking)
  • 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)

Because these edits all have a modifier indicator of “0,” that means you cannot bypass these edits with a modifier for any reason.

Example: Suppose your ob-gyn performs 58952 and wants to report 38765 as well. If you report both these codes, payers following NCCI edits will only reimburse 58952.

Check Your Hysterectomy Edits Before Reporting These Codes

CPT® 2022 brought you four new donor hysterectomy “T” codes, and not surprisingly, you have new edits to consider when your claim incorporates these new codes.

Remember: Category III codes are not reviewed by the Relative Value Scale Update Committee (RUC) and do not receive payment valuation, says Michael Weinstein, MD, a physician in Washington, D.C., and former member of the AMA’s CPT®’s Advisory Panel. “They are often considered ‘experimental’ services by insurance carriers and therefore will not be considered a covered benefit. A claim for payment will usually be followed by a denial which can be appealed,” he adds. Even so, CPT® guidelines strictly mandate the utilization of these Category III codes when they are specifically described for the procedure your ob-gyn performs. CPT® also specifies that a Category III code should be opted for over an unlisted procedure code under Category I.

The donor hysterectomy codes are as follows:

  • 0664T (Donor hysterectomy (including cold preservation); open, from cadaver donor)
  • 0665T (Donor hysterectomy (including cold preservation); open, from living donor)
  • 0666T (Donor hysterectomy (including cold preservation); laparoscopic or robotic, from living donor)
  • 0667T (Donor hysterectomy (including cold preservation); recipient uterus allograft transplantation from cadaver or living donor)

You should consider all these codes as being a part of all the regular hysterectomy codes. Some edits have a modifier indicator of “0,” meaning you can never separate these edits with a modifier, while others have a modifier indicator of “1.” That means you can apply an appropriate modifier if you have supporting documentation.

Takeaway: “Therefore, it behooves the coder to check NCCI edits carefully before billing any of these codes with a hysterectomy CPT® Category I code,” says Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.

Intradermal Cancer Immunotherapy Get Edits, Too

Speaking of Category III codes and NCCI edits, these intradermal cancer immunotherapy codes are now column 2 codes to all ob-gyn codes. The codes in question are:

  • 0708T (Intradermal cancer immunotherapy; preparation and initial Injection)
  • +0709T (… each additional injection (List separately in addition to code for primary procedure))

These edits have a modifier indicator of “1,” which means you can apply a modifier like 59 (Distinct procedural service), so long as you have documentation to support its use.

Example: As these new codes show promise for ovarian cancer, a gynecology oncologist most likely would report this type of immunotherapy. You may encounter instances when a gynecology oncologist might perform a biopsy on the same date of service. If you have supporting documentation, then you could apply a modifier to 0708T-+0709T to separate the edit.