Ob-Gyn Coding Alert

Reader Questions:

Consider Modifier XS For Separate Procedures

Question: I have a provider who performed a laparoscopic salpingectomy for sterilization and then he aspirated a cyst on the left ovary. Received a letter from carrier stating that this is an unbundling of services. A National Correct Coding Initiative (NCCI) edit states these codes can be submitted with the appropriate modifier. Is this correct?

The note is as follows:

The fallopian tubes appeared to be normal on both right and left sides. The fimbriated end however of the patient’s right fallopian tube was incorporated into the posterior peritoneum on the patient’s right side. The cul-de-sac was free. There was no evidence of endometriosis. The ovary on patient’s right side was normal however the left side contained 3 small cysts. The largest of the cysts was approximately 2-1/2-3 cm. Using a needle aspirator and 10 mL syringe each one of the ovarian cysts was entered with the needle aspirator and then the individual cysts were aspirated into the 10 mL syringe and specimens were sent for cytology. This decompressed the entire left ovary. The patient’s bleeding and hemostasis on the left ovary was normal. At this point the ureters were visualized on both right and left sides. The pelvic vessels were identified. The patient had the fimbriated end of the fallopian tube on the right tented medially and coming underneath the fallopian tube and above the peritoneum I was able to lyse adhesions with a curved Metzenbaum laparoscopic scissor.

Once this was done this freed the fimbriated end and I was able to now use the LigaSure to come across the tissue between the ovary and the fallopian tube. Electrocoagulation ×3 and then transection were done across the entire mesosalpinx to the cornu of the uterus on the right side. The fallopian tube was cross clamped and electrocoagulated and then transected. This freed the entire tube. The tube was brought up through the right port site. The same procedure was carried out on the contralateral side except without the adhesions.

Specimens would be labeled as right and left fallopian tubes.

What should I report?

Utah Subscriber

Answer: First of all, you have not stated which CPT® codes you billed for this procedure. The code for a laparoscopic tubal ligation (58671, Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) would not bundle the code for aspiration of ovarian cysts (presumedly you reported 49322, Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple)).

But if you instead billed a laparoscopic salpingectomy (58661, Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)), code 49322 is in fact bundled.

Keep in mind that many payers will not reimburse the higher amount for the salpingectomy (with 19.32 RVUs) instead of the code for a tubal (with 10.96 RVUs) when the purpose of the procedure is sterilization, rather than removal of the tubes for disease. The code combination of 58661 and 49322, although bundled, could be overridden using either modifier 59 (Distinct procedural service) or modifier XS (Separate structure…) because one procedure focuses on the fallopian tubes and the other on an ovary.

Keep in mind that not all carriers follow only NCCI edits. There are carriers that use NCCI as a base, and then add additional restrictions, and in this case that restriction may be the purpose of the salpingectomy. Appeal with op note and letter explaining the ovarian cyst aspirations were separate from removing the fallopian tubes to sterilize the patient.

And don’t forget you should have the appropriate different ICD-10-CM for each procedure.