Ob-Gyn Coding Alert

Question: My ob-gyn wants to use 58952 for a hysterectomy and BSO. He removed a large mass (which was not malignant) and tons of adhesions. He made no mention of removing the omentum, nor any lymph nodes. I thought of using modifier 52 on his code. I have enough documentation to warrant modifier 22 for the adhesions. What should I do?

North Dakota Subscriber

Answer: You-re right to question this code selection. Without a malignancy diagnosis, you cannot use a code (such as 58952, Resection [initial] of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy, with radical dissection for debulking [i.e., radical excision or destruction, intra-abdominal or retroperitoneal tumors]) that stipulates a malignancy presence.

Instead, you should use 58150 (Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]) for the TAH/BSO and 49203-49205 (Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, one or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors -) depending on the size of the mass.

Because you believe you have enough documentation to add modifier 22 (Increased procedural services) for adhesiolysis, you should apply this modifier on the primary procedure listed (the one that has the highest relative value unit).