Ob-Gyn Coding Alert

Warning: Not ordering your CPT^® codes correctly could affect your bottom line.

Staring at a complicated op note and feeling overwhelmed? You’re not alone. The best thing to do is to take a breath. Break down the note into five simple steps, and you’ll be sparing yourself a lot of headaches and potential mistakes.

Step 1: Check Your CPT^® Codes’ RVUs

The following op note lands on your desk. Your ob-gyn did a surgery using a laparoscopic approach. The ob-gyn’s documentation states:

“Preop dx: Painful left ovarian cyst. Procedure in order performed (two auxiliary ports):

1. Left ovarian cystectomy
2. Sharp dissection of dense adhesions from sigmoid to left adnexa and posterior uterus
3. Destruction of endometriosis left pelvic sidewall, vesicouterine reflection, and posterior cul-de-sac.”

First, you should identify all the procedures your ob-gyn performed by allotting them a code. Place these codes in order of their Relative Value Unit (RVU), listing the highest value code first. Don’t forget to append the appropriate modifier to all subsequent procedures unless they are represented by add-on codes.

For the left laparoscopic cystectomy, you would report 58661 (Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]) if the ob-gyn removed part of the ovary along with the cyst. If the ob-gyn removed the cyst intact, you would report 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method) for both the cyst and the destruction of the endometriosis. As for the lysis of adhesions part of this procedure, you would report 58660 (Laparoscopy, surgical; with lysis of adhesions [salpingolysis, ovariolysis] [separate procedure]).

So that’s 58661, 58662 and 58660 or possibly just 58662 and 58660. According to the RVU scale, the code 58662 has a higher RVU than 58661, so you should report that code first. But 58660 has a higher RVU than 58661, so you should list that second, says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

Step 2: Account for Surgical Standards

Review your list of codes. Identify and eliminate those codes that are surgical standards (such as those for exploratory laparotomy, diagnostic laparoscopy, diagnostic hysteroscopy, exam under anesthesia, hemostasis control, drain placement, a procedure checking the surgeon’s work, or accessing the surgical site by removing adhesions, or procedures that are considered a component of the surgery, and so on). You shouldn’t list codes for these inherent services when performed with other surgical procedures.

This means you may not be able to report the 58660 part of the surgical scenario because this code is a “separate procedure” and normally you would not report it in addition to the code for the total procedure. In other words, CPT^® considers this an integral component of some larger procedure. So you may have to strike that code off your list.

Step 3: Don’t Forget Any CCI Edits

Check the National Correct Coding Initiative (CCI) for coding edits. Eliminate code combinations CCI won’t allow (such as, lysis of adhesions).

If you look at CCI, you’ll see that both 58662 and 58661 aren’t bundled. But CCI bundles code 58660 into both 58662 and 58661, and you cannot bypass the edit with a modifier. This means this code does not belong on your claim.

Step 4: Add Modifier 22 for Extra Work

Add modifier 22 (Increased procedural services) to the primary code if the surgical report indicates that your ob-gyn did significant extra work for bundled codes.

For example, modifier 22 is the only way to get Medicare to pay attention to the work for lysis of adhesions because CCI permanently bundles lysis into many codes and you cannot use a modifier to bypass this edit. Using modifier 22 puts the claim into manual review. If your documentation supports the extra significant work, Medicare may pay for the lysis or the bundled code, Witt says.

If you’ve got the appropriate documentation supporting additional work, you should add modifier 22 to code 58662.

Step 5: Mull Over These Modifiers

Look for places where you can appropriately append a modifier. For example, if your documentation meets the criteria for reporting procedures bundled by CCI, you should add the appropriate modifier assigned by the payer to bypass the edit. For Medicare, some examples of these would be:

• modifier 59 (Distinct procedural service) 
• Or in lieu of modifier 59, one of the “X” modifiers:

            o XE (Separate encounter, A service that is distinct because it occurred during a separate encounter)
            o XS (Separate Structure, A service that is distinct because it was performed on a separate organ/structure)
            o XP (Separate Practitioner, A service that is distinct because it was performed by a different practitioner)
            o XU (Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service)

• modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) 
• 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), or 
• modifiers RT (Right side) or LT (Left side).

In the above scenario, you should add modifier 51 (Multiple procedures) to 58661 if the ob-gyn removed part of the ovary along with the cyst because you’ll report the primary procedure (58662) for the removal of the endometriosis.

Result: If your ob-gyn performed both types of removal in the surgical scenario, you’ll report 58662-22 and 58661-51 for this procedure if the work described in the lysis was significant. If the ob-gyn removed no part of the ovary along with the cyst, you’ll just report 58662-22.