Ob-Gyn Coding Alert

Question: A patient has indications for a TAH with BSO because of chronic incapacitating pelvic pain, probable adenomyosis or myometrium. In addition, she has multiple cul-de-sac adhesions or right or left adnexa adhesions, so much so that the adnexa are firmly adherent to either the rectosigmoid colon or lateral wall of the pelvis, requiring careful dissection prior to the TAH. What is the best way to file for this case? We usually file for the TAH with code 58150, and 58740-51 for the lysis adhesions. Most insurance companies deny the 58740 as inclusive. The same goes for patients with a moderate to severe form of endometriosis. Both cases require expertise, are time-consuming, and include the risk of injury to adjacent tissues, yet the insurance companies refuse to pay for the added time and responsibility.

Spyros D. Kitromilis, MD
Syracuse, NY

Answer: First, lysis of adhesions is almost always denied by insurance companies as being included with other abdominal procedures. But, this does not mean you cannot bill for them when the adhesions fall outside of the norm. That is, when they are dense, vascular, anatomy-distorting or add significant risk to the patient to remove. The problem with lysis of adhesion is that most physicians do not adequately document the work involved, do not use the correct modifier (i.e., -59), and do not send in supporting documentation with the claim. The modifier -59 is used to denote a distinct procedure. Refer to your 1999 CPT for a complete description. This modifier is frequently appended to CPT procedure codes that are designated as a CPT separate procedure. Codes that describe lysis of adhesions (enterolysis, ureterolysis, ovariolysis) generally are identified this way in CPT, which is why most payers deny the procedure code on first submission in the absence of the modifier 59 and supporting documentation.