Avoid Coding Errors for Endometriosis Involving the Bowel
Question: I’m coding an operative report for a patient with severe endometriosis. During the procedure, the surgeon excised endometriosis from the pelvic peritoneum and also removed a separate endometriotic lesion involving the bowel. Can I report both procedures, or is the bowel excision considered part of the peritoneal endometriosis excision? Revenue Cycle Insider Subscriber Answer: It depends on exactly what the surgeon documented and whether the bowel procedure represents a distinct surgical service. As you review the operative report, avoid assuming that every additional site of endometriosis automatically supports reporting another CPT® code. Your first step is to determine what work was actually performed. If the surgeon excised endometriosis from the pelvic peritoneum and separately performed a distinct bowel procedure, such as a partial colectomy for deeply infiltrating bowel endometriosis, you may be able to report both procedures if each is separately identifiable and medically necessary. Before assigning both CPT® codes, review the current National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edit tables along with any payer-specific bundling rules. Because NCCI edits are updated quarterly, you should always confirm code relationships based on the date of service. If an edit exists, determine whether it allows reporting with an appropriate modifier, such as modifier 59 (Distinct procedural service) or an X{EPSU} modifier, when documentation supports a truly distinct procedural service. Conversely, if the bowel was simply mobilized or superficial implants were removed from its serosal surface as part of the peritoneal dissection, that work is generally considered integral to the primary procedure and is not separately reportable. Example 1: A surgeon performs laparoscopic excision of pelvic peritoneal endometriosis. During the procedure, the surgeon carefully dissects several superficial endometriotic implants from the surface of the sigmoid colon without entering the bowel wall or performing a bowel resection. Answer: Report 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method). Because the surgeon removed only superficial implants from the bowel serosa as part of the pelvic peritoneal dissection, the bowel work is generally considered integral to 58662 and is not separately reportable. Example 2: A surgeon performs laparoscopic excision of pelvic peritoneal endometriosis. During the operation, the surgeon identifies a deeply infiltrating endometriotic lesion involving the rectosigmoid colon. The surgeon performs a laparoscopic partial colectomy with anastomosis to completely remove the diseased bowel segment. Answer: Report 58662 for the pelvic endometriosis excision and 44204 (Laparoscopy, surgical; colectomy, partial, with anastomosis) for the bowel resection, if documentation supports that the colectomy was a distinct procedure and NCCI edits do not prohibit separate reporting. Before assigning both codes, review the applicable NCCI PTP edits and determine whether a modifier, such as modifier 59 or an appropriate X{EPSU} modifier, is supported. As you review the operative report, confirm that the documentation clearly describes: If the documentation is unclear about the extent of bowel involvement or the procedure performed, submit a compliant physician query before assigning additional CPT® codes. Key: You should base your coding on the surgical work performed, not simply the presence of endometriosis in more than one anatomic location. Separate CPT® reporting is appropriate only when the operative report supports a distinct bowel procedure and the services are separately reportable under CPT® guidelines and NCCI policy. Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
