Outpatient Facility Coding Alert
Bill Separately for Paratubal Cyst
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Question: The physician performed a left salpingo-oophorectomy with drainage of right paratubal cyst and lysis of adhesions. Would the aspiration of the paratubal cyst be included in the salpingo-oophorectomy (58661)?
Maryland Subscriber
Answer: No. You should report 58661 (Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]) and 49322 (Laparoscopy, surgical; with aspiration of cavity or cyst [e.g., ovarian cyst] [single or multiple]).
Remember, as per Correct Coding Initiative (CCI) edits, code 49322 is a column 2 (component) code for the more comprehensive procedure code 58661. Therefore, if you are billing for both procedures on the same claim and have documentation to back this up, you need to append a modifier such as modifier 59 (Distinct procedural services) to the column 2 code 49322 before you can report both services. This will let the payer know the ob-gyn performed the drainage of paratubal cyst on the right side, which is a separate service from the left salpingo-oophorectomy. Some payers may require you to append modifier LT (Left side) to 58661 to more clearly make your case.
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