Wiki Lap. RSO, specimen drained in situ

[desireewhite185@yahoo.com]

Hello,
Our physician performed laparoscopic right salpingo-oophorectomy on a patient yesterday. He had to drain the cyst prior to removing as it wouldn't fit through the incision.
He is questioning if we can add modifier 22 for this. Here is the report. What do you think?



Appreciate your advice. This is the only part of the report that is documented on the ovary removal. Thanks, Desiree

 

[nielynco]

Hello,
Our physician performed laparoscopic right salpingo-oophorectomy on a patient yesterday. He had to drain the cyst prior to removing as it wouldn't fit through the incision.
He is questioning if we can add modifier 22 for this. Here is the report. What do you think?

View attachment 7089

Appreciate your advice. This is the only part of the report that is documented on the ovary removal. Thanks, Desiree

And how much longer did this take him? If he had documented significant additional time it might get some attention for additional reimbursement, but with just this statement I think you won't have a good case for using -22.

 

[csperoni]

I agree that with the information supplied, I would not use -22. I tell my clinicians that if they expect extra payment, they need to document clearly there was additional work. With current documentation, I would not say it is particularly complex, and could have literally added 4 minutes to the surgery.