Wiki need help with understanding cpt code 49000

[rockylopez]

Hello. I am coding for a cosurgeon case and I am stuck with coding what was initially laparoscopic and converted to open. The op report is confusing in determining how i should code the procedure I am gearing towards 49000 but really could use some help. Thank you

PROCEDURE in DETAIL:
Upon entering room, evaluated by laparoscopy large complex right ovarian mass with both solid and cystic components. I went ahead and scrubbed
to better take a look. pt is postmenopausal with ascites and what could be b/l ovarian fibromas, vs neoplasm. right ovary with enlarged cyst was
noted and using Harmonic scalpel IP identified and ovary with cyst was excised.
Using already a vertical supraumbilical skin incision which was already made was used to enter the peritoneal cavity and remove the large right
complex solid and cystic ovary which measures ~ 15 x 13 x 11 cm was removed intact through this incision. This uterus and left ovary were also
palpated through this incision and also left ovary was found to have a large adnexal mass as well also with solid and cystic components. using the
vertical supraumbilical midline incision, this incision was extended inferiorly to allow better exposure and access to left adnexa. uterus was 4 cm x 4
cm is size, normal appearing with small anterior fibroid, otherwise normal. left ovary with 10 x 6 x 8 cm complex adnexal mass. left IP identified
and both left tube and ovary with enlarged cyst was excised using Kelly clamps. pedicle was suture ligated with 0 Vicryl in transfixion suture x 2.
and specimen of left tube and left ovary with complex cyst was taken off field and also will be sent to path for permanent
Hemostasis noted at both sites of pedicles.
My part of procedure was completed and I remained to assist Dr. in further exploration, umbilical hernia repair, abdominal wall closure. See
remainder of details in the OP note.

Pathology: right ovary with enlarged complex cyst and left ovary with large complex cyst and left tube

 

[csperoni]

Based on the information here, it looks like this provider removed a right ovary with attached cyst, then also left ovary & tube with attached cyst, so a bilateral oophorectomy.
What is less clear to me is whether the provider performed the surgery itself via laparoscope vs open. This needs a provider query and possibly additional documentation to make things clearer. Assuming the information is sequential, then it appears the right ovary was detached laparoscopically, with an enlarged incision just to remove the specimen. On the left, it seems like a larger incision was made and then left surgery was performed open. IF my interpretation is correct, this would be coded as an open salpingo-oophorectomy 58720 since it started laparoscopic but turned into open. IF instead both right and left ovaries were detached via laparoscope (with incision just to remove specimens), then laparoscopic salpingo-oophorectomy 58661-50.

49000 is for exploratory laparotomy only. Basically nothing is being removed, so that is definitely not the best code.

If it meets co-surgery requirements (different specialties and separate op notes), I would put -62 on the salpingo-oophorectomy code, and BOTH physicians will bill that code (along with any other surgeries performed). If not, the 2 physicians will need to come to a consensus about who gets to bill what.
It also looks like this surgeon assisted the other physician in a hernia repair, so that would be billed with -80 (or possibly -82 if a teaching hospital).
Keep in mind not every surgery performed with another physician is "co-surgery". Sometimes a general surgeon does their portion, and a gynecologist does their portion. Co-surgery is when 2 physicians of different specialties each perform part of a surgery that is described by a single code. A clear cut example would be obgyn removes left tube & ovary. Frozen section comes back suspicious, so gynonc is called in. Gynonc evaluates, discusses with family, and determines only right tube & ovary will be removed and performs that. 58720-62 would be billed by both physicians. If Dr. #2 is also an obgyn, then co-surgeons may not be billed and the physicians will need to decide between themselves who gets to bill as primary, and the other as assist.
However, if in the same example after evaluation, it is decided a radical hysterectomy with pelvic and para-aortic lymph nodes will be performed in addition to the right salpingo-oophorectomy, then gynonc would bill as primary for 58210 and obgyn as assist 58210-80. In that situation, there is a single code that best describes the work, and gynonc did the majority of it.

I think you've posted a couple of questions for this same provider. I recommend open conversations with the provider. Always be respectful and make it clear you are never questioning medical decisions. However, the documentation needs to better explain what took place so that you can code and credit the physician properly for all the work being performed. Sometimes there are clues that make it clearer for someone with medical training, but 99% of coders did not receive medical training. Ask your physician to explain some of these things to you in more everyday terms. Maybe explaining which tools are definitely laparoscopic vs which tools are definitely open. Having a receptive physician where you can have a dialogue goes a long way to learning some of the nuances and complexity of subspecialties. If the physician works with a specific PA or NP, they can also be a resource for you.

 

[rockylopez]

Based on the information here, it looks like this provider removed a right ovary with attached cyst, then also left ovary & tube with attached cyst, so a bilateral oophorectomy.
What is less clear to me is whether the provider performed the surgery itself via laparoscope vs open. This needs a provider query and possibly additional documentation to make things clearer. Assuming the information is sequential, then it appears the right ovary was detached laparoscopically, with an enlarged incision just to remove the specimen. On the left, it seems like a larger incision was made and then left surgery was performed open. IF my interpretation is correct, this would be coded as an open salpingo-oophorectomy 58720 since it started laparoscopic but turned into open. IF instead both right and left ovaries were detached via laparoscope (with incision just to remove specimens), then laparoscopic salpingo-oophorectomy 58661-50.

49000 is for exploratory laparotomy only. Basically nothing is being removed, so that is definitely not the best code.

If it meets co-surgery requirements (different specialties and separate op notes), I would put -62 on the salpingo-oophorectomy code, and BOTH physicians will bill that code (along with any other surgeries performed). If not, the 2 physicians will need to come to a consensus about who gets to bill what.
It also looks like this surgeon assisted the other physician in a hernia repair, so that would be billed with -80 (or possibly -82 if a teaching hospital).
Keep in mind not every surgery performed with another physician is "co-surgery". Sometimes a general surgeon does their portion, and a gynecologist does their portion. Co-surgery is when 2 physicians of different specialties each perform part of a surgery that is described by a single code. A clear cut example would be obgyn removes left tube & ovary. Frozen section comes back suspicious, so gynonc is called in. Gynonc evaluates, discusses with family, and determines only right tube & ovary will be removed and performs that. 58720-62 would be billed by both physicians. If Dr. #2 is also an obgyn, then co-surgeons may not be billed and the physicians will need to decide between themselves who gets to bill as primary, and the other as assist.
However, if in the same example after evaluation, it is decided a radical hysterectomy with pelvic and para-aortic lymph nodes will be performed in addition to the right salpingo-oophorectomy, then gynonc would bill as primary for 58210 and obgyn as assist 58210-80. In that situation, there is a single code that best describes the work, and gynonc did the majority of it.

I think you've posted a couple of questions for this same provider. I recommend open conversations with the provider. Always be respectful and make it clear you are never questioning medical decisions. However, the documentation needs to better explain what took place so that you can code and credit the physician properly for all the work being performed. Sometimes there are clues that make it clearer for someone with medical training, but 99% of coders did not receive medical training. Ask your physician to explain some of these things to you in more everyday terms. Maybe explaining which tools are definitely laparoscopic vs which tools are definitely open. Having a receptive physician where you can have a dialogue goes a long way to learning some of the nuances and complexity of subspecialties. If the physician works with a specific PA or NP, they can also be a resource for you.

Thank you so much for your detailed response. I do appreciate it. I did send query to provider and this is the response when I inquired the procedure,
Intraoperative Consult: bilateral adnexal masses, ascites, laparoscopic right oophorectomy, ex-lap and left salpingo-ophorectomy
Surgeon.

I am gearing towards 58720,62 for my providers part of the surgery. in regards to cosurgeron modifier the other doctor is a trauma surgeon.
I am awaiting received the op report for the trauma surgeon to confirm that my provider assisted the hernia repair.

Thank you.