Coding FAQs

Surgeon should document assistant in the operative report. Assistant does not need to sign the operative report. For an assistant to bill in a teaching hospital it must be documented that no qualified resident was available or what exceptional medical circumstances existed to require the assistant. The assistant needs to bill the same surgical code as the surgeon, with either modifier -80 (Assistant Surgeon) or modifier AS (PA, NP or Clinical Nurse Specialist assistant in OR). Check with your regional carriers to determine which modifiers they recognize.

One of the problems lies in the fact that Medicare's CCI bundles an omentectomy into code 58210 and will not allow it to be paid even with a modifier. Therefore, they may not be willing to pay additionally for the omentectomy even though the code does not include a total omentectomy. A number of other payers also use the CCI as part of the claims review process. You might try having the surgeon dictate a general letter indicating the need for the total omentectomy and the work involved including the additional time and risk. The letter should clearly indicate that the procedure is not a partial omentectomy. Another coding alternative might be code 58954 but this includes a debulking and assumes there is intra-abdominal disease.

The series 58950-58952 can only be used with ICD10 codes for ovarian, tubal or primary peritoneal malignancy. 58953-58954 may be used with any diagnosis. All describe various combinations of procedures commonly performed for advanced gynecologic cancers.

Medicare's Correct Coding Initiative (CCI) bundles 58720 into the payment for 49203 and does not allow it to be reported even with a modifier.

No. Debulking codes are designed for when there is tumor outside of the ovary/fallopian tube/endometrium. If there is only staging performed, then the more appropriate codes are 58943 or 58950-58951.

Code 58956 includes a TAH/BSO with total omentectomy. If this is the only staging performed, then this would be appropriate. A more likely choice would be code 58951, which includes a TAH/BSO, omentectomy, and P&P nodes.

There is no specific CPT code for intraoperative intraperitoneal heated chemotherapy administration. This procedure may be performed at the same surgical session following removal of all gross tumors from the abdominal cavity. Prior to completion of the surgical procedure, a warmed chemotherapy solution is administered directly into the abdominal cavity, allowed to dwell, and then drained while the patient is under general anesthesia. If the instillation of the hyperthermic chemotherapy solution is a planned, integral part of the surgical procedure, it may be reported with code 96549 (unlisted chemotherapy procedure), or alternatively with modifier -22 on the primary surgical code as the hyperthermic chemotherapy solution administration adds time to the surgical time and requires physician/operating suite staff work above and beyond that of the surgical procedure. CPT code 96446 is intended to report intraperitoneal chemotherapy administered through a permanently placed intraperitoneal catheter so is not appropriate for HIPEC.

The CPT global surgical package includes all routine postoperative visits but payment rules vary depending on insurance carrier. The global package for Medicare includes the treatment of all complications managed outside the operating/procedure room. If a complication requires a return to the OR that can be reported with the appropriate surgical code, appending modifier 78 (unplanned procedure during the global period). For non-Medicare payers, you can report any additional E/M services above routine care for services related to the surgery, such as care for wound infections. If visits for conditions unrelated to surgery are provided in the global period, these can be reported by appending modifier 24. Modifier 24 is used for E/M services provided in the global period that are "unrelated" (e.g. a UTI or breast lump) or otherwise not part of routine postop care.

The ICD-10 code for an evaluation prior to chemotherapy is Z01.818 (encounter for examinations prior to antineoplastic chemotherapy). Z51.11 is attached to the billing for the administration of chemotherapy so would not be used by the provider when the patient is going to a hospital-owned infusion center.

49205 is not to be used in this circumstance. The procedure described is an oophorectomy and the code 58720 is the same regardless of the size of the ovary. If there is excessive work required it should be documented in the operative report and a modifier 22 may be added. The 4920X codes are used when managing masses not involving the uterus, cervix, fallopian tube or ovary.  

Those procedures are included as “debulking”. 58957 is a code that is used for resection of recurrent gynecologic cancer. If you are doing a primary debulking then you should use 58952-58954 depending on what else is done.

If there was described debulking of peritoneal implants, whether or not they turned out to be viable malignancy, use a debulking code- i.e. 58953. In the context of extensive debulking without omentectomy, it is reasonable to not reduce it with a 52. If there was just lysis of adhesions without debulking, then 58150-22 or 58956-52.

Yes, it is required for ICD-10 to identify the primary site of the tumor as well as sites of metastatic disease. Cancer codes for sites of metastatic disease are designated as “secondary cancer”. For example, a stage 4 ovarian cancer may be coded using 3 codes: C56.1 (malignant neoplasm of the right ovary), C78.6 (secondary malignancy of the peritoneum and retroperitoneum, and J91.0 (malignant pleural effusion).

Borderline ovarian tumors are “low malignant potential” not “no malignant potential”. There is therefore controversy about which code set to use. The options are: D39.1 Neoplasm of uncertain behavior of ovary D39.10 Neoplasm of uncertain behavior of unspecified ovary D39.11 Neoplasm of uncertain behavior of right ovary D39.12 Neoplasm of uncertain behavior of left ovary C56 Malignant neoplasm of ovary C56.1 Malignant neoplasm of right ovary C56.2 Malignant neoplasm of left ovary C56.9 Malignant neoplasm of unspecified ovary When using CPT codes that are designated for use for ovarian malignancies, e.g. 58950 (resection of ovarian malignancy with BSO and omentectomy) a cancer code should be used. Histological types such as mucinous tumors are not included in ICD-10 codes. However, they are included in the ICD-Oncology codes. By and large, these are not needed for medical coding, but are important for tumor registries.

For a laparoscopic BSO with staging (for a patient with prior hysterectomy, for instance), you can use the CPT code 38573 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when performed) with a -22 modifier. That would be billed with the laparoscopic BSO CPT code 58661 with the -59 modifier for a second surgery. With any -22 modifier, you would need to have an operative note and letter requesting increased reimbursement with the rationale, in this case the extra time and effort for “debulking”. For a laparoscopic appendectomy at the time of another procedure, the coding choice is code 44970 (laparoscopic surgical appendectomy). You will need to append modifier 59 to this code to indicate it is separate and distinct from the other surgery. The operative report documentation should clearly describe the procedure and the reason for performing it. You should also append a distinct ICD code, such as C78.5, secondary malignant neoplasm of the large bowel.

In 2018, the CPT code 38573 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when performed.) was created to address situation where a Gyn Onc is asked to perform staging where another surgeon has performed the laparoscopic BSO ± hysterectomy. This code specifically excludes hysterectomy codes. If you perform a laparoscopic hysterectomy, BSO, debulking, the proper CPT code would be 58575 (Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed).

Use code 38573 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when performed.) with a -52 modifier if not all of the components were performed. In addition, you can use laparoscopic BSO CPT code 58661 with the -59 modifier for a second surgery

The best approach is to report code 58953 (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking) plus the appropriate colectomy code (e.g.44145) or other more appropriate code. If there was also a takedown of the splenic flexure, then you would also report code +44139 (Mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy). Code +44139 is not subject to multiple procedure reduction since it is an add-on code.

You can use 58954 (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy) with modifier 52. The 52 modifier indicates a "reduced service" since the hysterectomy component was not performed. Not all payers recognize modifier 52 so that the full allowable amount may be reimbursed for the procedure. You can choose to decrease your fee as you deem appropriate. The appropriate colectomy code (e.g. 44145) should also be added to this procedure with a 59 modifier for multiple procedures.

The codes for ovarian cancer procedures are in the 58943-58958 for open procedures. The options for the above would be to code 58951 (Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy). If radical dissection for debulking is done, then you would report code 58954 (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy). Codes 58953-58956 can be used for cancer at all sites including the uterus. Although the selection of codes for treatment of gyn malignancy is fairly robust, there may be those occasions when the procedure actually performed is varied slightly from the available codes. In these instances, you can consider appending either a 52 (reduced services) or 22 (increased services) modifier to the basic procedure.