Laparoscopy Oophorectomy with Biopsies of Peritoneum, Omentum

natashalage

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Hello Coding Community! :) I would like to confirm that we cannot add -22 or cpt for Biopsies in my scenario below? I feel I might miss extra reimbursement for extra work on biopsies but CCI edits tell me- cannot add them. Do you think I could add modifier -22 at least? Thank you very much for your help in advance.
Code 58661(column 1) has a CCI conflict with code 49321(column 2). A modifier is allowed to override this relationship.

58661Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)

49321Laparoscopy, surgical; with biopsy (single or multiple)

Specimen(s) Received
A:Right ovary (FS)
B:hepatic diaphragm peritoneal biopsy
C:spleenic diaphragm peritoneal biopsy
D:left paracolic peritoneal biopsy
E:right paracolic gutter peritoneal biopsy
F:bladder peritoneal biopsy
G:greater omentum

OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS:
1. 3cm solid mass of the right ovary
OPERATION:
1. Diagnostic laparoscopy
2. Right oophorectomy
3. Peritoneal biopsies
4. Omental biopsy
5. Peritoneal washings

CLINICAL INDICATIONS:
h/o menorrhagia ,.. dysmenorrhea, found an intramural fibroid and a focal adenomyoma,..

FINDINGS:
1. Exam under anesthesia was significant for a uterine cervix that was mobile. ..
2. Diagnostic laparoscopy was significant for no evidence of peritoneal disease.
3. The bilateral ureters were seen to peristalse spontaneously along their course through the pelvic retroperitoneal dissection beds.
4. Normal left and right Fallopian tubes, normal left ovary.
5. The right ovary was enlarged with hematogenous cysts and there was a raised lesion on the ovary surface which was concerning for an epithelial proliferation, clinically at least a borderline tumor.
5. Normal omentum and upper abdomen.
DESCRIPTION OF PROCEDURE: ..

A Veress needle was placed into the umbilical plate and the peritoneal cavity was entered. C02 gas confirmed low pressure and the abdomen was insufflated. A periumbilical skin incision was made and an 11mm trocar was introduced into the peritoneal cavity. Two 5mm ports were also introduced under direct visualization lateral to the epigastric vessels. An additional port was placed in the left upper quadrant. …

The bowel was mobilized from the left pelvic sidewall and its attachments to the pelvic peritoneum to allow it to be reflected out of the pelvis. The right Fallopian tube was elevated and the mesosalpinx was fulgerated and transected with Ligasure to maintain the normal tube with the uterus. We then identified the peritoneum overlying the external iliac artery on the right which was incised with Ligasure. The peritoneum was divided parallel to the gonadal artery and vein. The ureter was identified in the retroperitoneal space and an avascular plane superior to the ureter was excised to isolate the gonadal artery and vein at the pelvic brim. This was fulgerated and transected. The peritoneal attachments were resected to isolate the right ovary and mass. The utero-ovarian ligament was fulgerated and transected. The ovary was then placed into an Endocatch bag and removed from the peritoneal cavity and sent to pathology for review...
Given the gross concern for an epithelial proliferation consistent with at least borderline I proceeded with geographic peritoneal biopsies using the biopsy forceps....
The omentum was then reflected into the pelvis and the transverse colon identified. The right gastroepiplic vessels were then fulgerated and transected with Ligasure. The greater omentum was then dissected away from the transverse colon with good visualization of the colon throughout. The left gastroepiplic vessels were then fulgerated and transected and the omentum was placed into an endocatch bag, removed from the peritoneal cavity and sent to pathology for review.

Frozen section diagnosis was notable for a serous cystadenoma with a focal proliferation. As such, no further staging procedures were performed.
 

Cmama12

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Just looking this over briefly, IMHO I would say the biopsies are incidental, particularly as there is not a separate dx to attach. Unsure if the work of removing the omentum warrants a 22 modifier - you would need to go back to the provider and ask, and they need to have a statement saying why a 22 modifier is applicable.
 

csperoni

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If this were open, and final path comes back as malignancy, then 58950 would be the code. However, it's laparoscopic and there is no exact equivalent.
I would have no problem with putting a -22 on this - several biopsies, and greater omentum was removed. The other alternative would be to use unlisted, but I avoid those when there is a reasonable alternative.
 
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