Wiki Diagnostic Laparoscopic vs conversion to Mini laparotomy

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rockylopez

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Hello fellow coders. I wanted to ask if anything can assist me with this surgery that i am contemplating on the cpt codes for the surgery.
Pre-procedure diagnosis:
1. Abdominal pain
2. Left ovarian mass
Post-procedure diagnosis:
Left adnexal mass
Procedures performed:
1. Diagnostic laparoscopy
2. Deflation of left adnexal mass
3. Conversion to minilaparotomy
4. Partial removal of left ovarian mass
Technique/Procedure:
laparotomy
Operative findings:
1. 12 cm left adnexal mass with 550 cc of old blood (like "chocolate cyst")
2. Normal uterus, right fallopian tube and right ovary
3. Adhesions of the omentum to the anterior abdominal wall.
4. Adhesion of the left adnexal mass to the posterior uterus and cul-de-sac.
Complications: conversion to minilaparotomy

I am gearing toward CPT code 49000 and 58661 with modifier 22 on 49000. if anything can please give me any input that would be helpful. Thank you
 
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What's not clear to me from this is why/when the conversion took place, which makes all the difference for coding.
It's not particularly unusual for a physician to enlarge one of the trocar sites at the end of the surgery just to remove a large specimen. This could be an enlarged uterus, or perhaps in your case, a 12cm cyst. IF that's the situation, you would NOT separately code for the removal; it is simply part of the surgery. Whether or not it warrants -22 depends on the documentation.

Sometimes, a procedure starts laparoscopic and is converted to an open procedure. This could be due to patient's anatomy, unable to access a particular area via laparoscope, dense pelvic adhesions, visualization difficulty, etc. When that is the situation, the surgery (or a portion) is actually being performed as open abdominal. Those cases are coded by the way the surgery was completed.

With the information provided here, I am unable to tell whether it is situation 1, situation 2, or perhaps a very unusual situation 3.

In any of the situations, you would not code 49000 and 58661.
Situation 1: 58662 for laparoscopic ovarian cystectomy. I do not see documented a portion of the ovary or tube removed; if so, then 58661-LT. It is POSSIBLE -22 is appropriate, but it is definitely not justified by the documentation here.
Situation 2: 58925 for open ovarian cystectomy. Again, it is POSSIBLE -22 is appropriate, but not justified in this documentation provided.
 
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csperoni said:
What's not clear to me from this is why/when the conversion took place, which makes all the difference for coding.
It's not particularly unusual for a physician to enlarge one of the trocar sites at the end of the surgery just to remove a large specimen. This could be an enlarged uterus, or perhaps in your case, a 12cm cyst. IF that's the situation, you would NOT separately code for the removal; it is simply part of the surgery. Whether or not it warrants -22 depends on the documentation.

Sometimes, a procedure starts laparoscopic and is converted to an open procedure. This could be due to patient's anatomy, unable to access a particular area via laparoscope, dense pelvic adhesions, visualization difficulty, etc. When that is the situation, the surgery (or a portion) is actually being performed as open abdominal. Those cases are coded by the way the surgery was completed.

With the information provided here, I am unable to tell whether it is situation 1, situation 2, or perhaps a very unusual situation 3.

In any of the situations, you would not code 49000 and 58661.
Situation 1: 58662 for laparoscopic ovarian cystectomy. I do not see documented a portion of the ovary or tube removed; if so, then 58661-LT. It is POSSIBLE -22 is appropriate, but it is definitely not justified by the documentation here.
Situation 2: 58925 for open ovarian cystectomy. Again, it is POSSIBLE -22 is appropriate, but not justified in this documentation provided.
Click to expand...
Thank you so much for your response, only the part of the ovarian cyst wall was removed, and the only specimen documented that was sent to pathology, so i am gearing towards 58925. The sentence below is why I feel that modifier 22 is supported.

Was difficult to find planes or dissection from the left sidewall to the cyst and thus the decision to convert to a mini laparotomy was made.
 
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With that additional information, 58925 does seem like the correct code. That one sentence alone would not be enough for me to use -22.
22Increased procedural services. When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service.

Here are a few references about -22
https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/modifier-22

I would also add on ICD10 Z53.31 Laparoscopic surgical procedure converted to open procedure
 
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csperoni said:
With that additional information, 58925 does seem like the correct code. That one sentence alone would not be enough for me to use -22.
22Increased procedural services. When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service.

Here are a few references about -22
https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/modifier-22

I would also add on ICD10 Z53.31 Laparoscopic surgical procedure converted to open procedure
Click to expand...
Thank you very much for your guidance and help. I appreciate it.
 
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