Ob-Gyn Coding Alert

A quick way to determine when you need to append modifier 22

A mistake as simple as "mis-sequencing" your CPT codes can result in some serious reimbursement complications. Steer clear of these complications with these five steps you can follow every time you face an intricate op note.

Getting started: "Read through the entire report. The doctor's summary of diagnosis and procedures at the beginning of the op report doesn't always include all the important details of the procedure," says Amy Long, RHIT, CPC, an ob-gyn certified coder at Dodge City Medical Center in Kansas.

Step 1: Rank Codes in RVU Order

The following op note lands on your desk. Your ob-gyn did a surgery using a laparoscopic approach. His 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.

Step 2: Eliminate 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, and so on). You shouldn't list codes for these inherent services when performed with other surgical procedures.

This means you shouldn't report the 58660 part of the surgical scenario because this code is a "separate procedure." You shouldn't report it in addition to the code for the total procedure. In other words, CPT considers this an integral component of some larger procedure, Long says. So you may have to strike that code off your list.

Step 3: Note Any NCCI Edits

Check the National Correct Coding Initiative (NCCI) for coding edits. Note: You can see the edits online at http://www.cms.hhs.gov/physicians/cciedits/. Eliminate code combinations NCCI won't allow (such as, lysis of adhesions).

If you look at NCCI, you'll see that both 58662 and 58661 aren't bundled. But NCCI bundles code 58660 into both 58662 and 58661, which means this code does not belong on your claim.

Step 4: Add Modifier 22 for Extra Work

Add modifier 22 (Unusual 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 NCCI 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.

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

Step 5: Mull Over Other Modifiers

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