Ob-Gyn Coding Alert

Question: Can I code separately for an omental biopsy when a bilateral salpingo-oophorectomy (BSO) is performed? The physician used an abdominal approach for the BSO and then excised a piece of the omentum for biopsy.

New Jersey Subscriber

 
Answer: Most payers include a biopsy performed close to the surgical field as part of the primary procedure, in this case 58720 (Salpingo-oophorectomy, complete or partial, unilateral or bilateral [separate procedure]). There is no specific code for the omentum because it is a covering and not an organ: None of the procedures described in CPT fit this circumstance since the surgical field is already exposed. It does not appear that the physician did any significant additional work in removing the sample for biopsy, so the omental biopsy would be included. If the physician documented significant work in obtaining the sample for biopsy, add modifier -22 (Unusual procedural services) to the BSO code or report unlisted-procedure code 49999 (Unlisted procedure, abdomen, peritoneum and omentum).