James Burke, MD
There are instances when gynecologic oncologists are called to assist with brachytherapy as part of the treatment of patients with cervical, vaginal, or recurrent endometrial carcinomas. However, medical coding for the work of these procedures is not straight forward as specific Current Procedural Terminology (CPT) codes do not exist. Below are vignettes where a gynecologic oncologist may assist with brachytherapy procedures and how those procedures might be coded.
Case number 1: The patient is a 47-year-old female with stage IIIB, grade 3 squamous cell carcinoma of the cervix who is undergoing radiation with concurrent chemotherapy. She is now ready for her brachytherapy and the radiation oncologist has asked you to place a Smit sleeve, a stent for (high dose rate (HDR) brachytherapy, to aid in placement of tandem and ovoids. There are two ways to code for the work of these procedures:
A) The gynecologic oncologist and the radiation oncologist perform the procedure together. The gynecologic oncologist performs a cervical dilatation and secures the Smit sleeve (HDR stent) with sutures while the radiation oncologist places the tandem and ovoids for the brachytherapy radiation. The most appropriate code for the procedure would be for the gynecologic oncologist AND the radiation oncologist both to bill 57155 (Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy) and use a -62 modifier for two physicians are working together. The gynecologic oncologist cannot bill for the cervical dilatation (57800) as it is considered part of the 57155 code.
B) The radiation oncologist asks the gynecologic oncologist to place a Smit sleeve for brachytherapy. The most appropriate way to code this procedure is to use 57155 with a -52 modifier to reflect reduced work for the procedure (the gynecologic oncologist is not placing the tandem and ovoid). You cannot bill for the cervical dilatation (57800) for the same reason as mentioned above. If the gynecologic oncologist places the tandem and ovoid, the appropriate code would be 57155 without a modifier as the entire procedure would be carried out by one physician.
Case number 2: A 65-year-old female patient with stage IB, grade 1 endometrioid carcinoma of the endometrium is found to have recurrent disease with a solitary nodule at the vaginal cuff. The patient has had no prior radiotherapy. The gynecologic oncologist takes the patient to the operating room where the lesion is excised from the vaginal apex and fiducial markers are placed in the periphery of the resection for radiation planning.
· The excision is coded as a simple partial vaginectomy 57106, and the add-on CPT code +49412 for placement of fiducial markers into the vaginal tissue at the vaginal apex.
Case number 3: The patient is an 81-year-old female patient with a stage IB, grade 3 endometrioid carcinoma of the endometrium was recommended to have vaginal brachytherapy for adjuvant treatment. The gynecologic oncologist placed the vaginal cylinder for her vaginal brachytherapy treatment.
· The most appropriate code for this work is 57156.
Case number 4: The patient is a 58-year-old female with stage IIIB, grade 2 squamous cell carcinoma of the vagina. The patient has completed her external beam radiotherapy with concurrent chemotherapy
and is now ready for her brachytherapy. The gynecologic oncologist has been asked to assist in placement of the interstitial needles for brachytherapy. The radiation oncologist places the interstitial needles, transperineal. The gynecologic oncologist performs a laparoscopic procedure to help guide placement of the needles and assure no needle tip is protruding into the peritoneal cavity.
· The radiation oncologist would code 55920 for placement of the interstitial needles/device and the gynecologic oncologist would code 49320 for a diagnostic laparoscopy.
James J. Burke, II, MD, is a Professor and Director of Gynecologic Oncology at Mercer University School of Medicine in Savannah, GA.