Start by asking the right questions.
Coding for gynecologic oncology procedures can be complicated. Procedure codes differ depending on whether the procedure is laparoscopic versus open and whether there is lymph node sampling or modifier usage. It’s important for medical coders to know the differences in procedures to ensure proper reporting.
The Society of Gynecologic Oncology (SGO) is a valuable resource for gynecologic oncology coding information. The SGO holds coding webinars throughout the year as well as a half-day coding course during their Annual Meeting on Women’s Cancer each March. Visit their website to register for coding courses and access past answers to common coding questions. Here are just a few coding questions and answers to help sharpen your gynecologic oncology coding skills.
SGO FAQs for Gynecologic Oncology Claims
Question: Is it appropriate to bill CPT® 50715 bilaterally when the provider documents “retroperitoneal fibrosis?” We have used the code 50715 when done open and 50949 when done laparoscopically. It has also been suggested we use modifier 22 on the primary procedure. Most of the scenarios are hysterectomy, BSO [bilateral salpingo-oophorectomy], omentectomy, and/or debulking with ureterolysis.
Answer: CPT® 50715 Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis describes an open procedure performed for a distinct diagnosis that’s also known as Ormond’s disease (N13.5). The disease is characterized by excess fibrous tissue developing in the retroperitoneal space behind the stomach and intestine. The code is not meant to be used for ureterolysis performed due to post-inflammatory changes or postoperative adhesions.
There is no analogous code for a laparoscopic approach. CPT® 50949 Unlisted laparoscopy procedure, ureter is an unlisted code and is not specific to ureterolysis. With this in mind, most insurance companies will require you to include supporting documentation and may be the cause of your denials.
If the procedure is done in conjunction with another laparoscopic procedure, you should append modifier 22 Increased procedural services to the main laparoscopic procedure in lieu of billing the unlisted code.
Additional work may be the result of one or more of the following:
- Increased intensity
- Increased technical difficulty of the procedure
- Severity of the patient’s condition
- Increased physical and mental effort required
Any increased work and time should be clearly documented and quantified in the operative note.
Question: How do you code when a patient has both a radical vulvectomy (partial or complete) and bilateral inguinal femoral lymphadenectomy done by two surgeons?
Answer: When two surgeons perform distinct parts of a single surgical procedure, they are acting as co-surgeons. The Medicare Physician Fee Schedule lists CPT® 56632 Vulvectomy, radical, partial; with bilateral inguinofemoral lymphadenectomy as a category 2 code, indicating that co-surgeons are permitted with no additional documentation if the surgeons are of different specialties (e.g., gynecology oncology and plastic surgery). When billing as co-surgeons, each must use the same code with modifier 62 Two surgeons appended. Each will be paid 62.5 percent of the global surgery fee schedule amount.
If the surgeons are of the same specialty, documentation that clearly explains the medical necessity for two surgeons will be required.
Question: How do you decide between 56501 and 56515? What constitutes “extensive” versus “simple?” What needs to be documented to justify extensive ablation?
Answer: Use CPT® 56501 Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) to report single, simple lesion destruction and 56515 Destruction of lesion(s), vulva; extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) to report multiple or complicated destruction of extensive vulvar lesions.
CPT® does not define what constitutes a “simple” treatment versus one that is “extensive.” Time, effort, complexity of the therapy, number of lesions, size of the lesions (several isolated lesions versus one large contiguous cluster), and risk should all be taken into consideration in making the final selection. Documentation should support the code and may be required if denied/requested by the insurance company.
Question: Can CPT® 58575 be used and modified if no debulking is done? All other elements are complete. Would you need to modify it with the 52 modifier? Provider note:
Robotic assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral injection for sentinel lymph node mapping and right sentinel lymph node biopsy, left full pelvic and paraaortic lymph node dissection, omental biopsy.
Answer: CPT® 58575 Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed requires tumor debulking. In the case where no debulking takes place, you would code the hysterectomy with removal of tubes and/or ovaries (58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) or 58573 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)) and lymph nodes separately (38572 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple with modifier 51 Multiple procedures appended or 38572). If the uterus was less than 250 grams, then use 58571. If more than 250 grams, use 58573. CPT® 38571 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy is for total pelvic lymphadenectomy only. To code for bilateral sentinel node mapping including the injection of dye, use add-on code 38900 Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure) with modifier 50 Bilateral procedure appended and 38570 Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple for the lymph node biopsy. If full node dissection needs to be done because of non-mapping or some other reason, you can still bill 38900-50 if the injection was done.
Question: What is billed when a radical hysterectomy is performed with bilateral pelvic lymph node dissection with no paraaortic node sampling?
Answer: Bill CPT® 58210 Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s) with modifier 52 Reduced services if no paraaortic node sampling was completed.
Spread Awareness Every Month
Ovarian cancer ranks fifth in cancer deaths among women and is the deadliest of the gynecologic cancers, with a five-year survival rate of 46 percent. Because of the location of the ovaries in the body, most ovarian cancers are not diagnosed until the late stages. Additionally, there is no screening test for ovarian cancer. Many are surprised to hear that a Pap smear does not detect ovarian cancer. So while ovarian cancer is hard to detect and is often treated late, there are signs and symptoms that can be recognized by patients and their families. An easy way to identify and remember the symptoms is with the acronym BEAT:
- Bloating that is persistent
- Eating less, feeling fuller
- Abdominal and/or back pain
- Trouble with your bladder and bowels
If you have these signs and symptoms, make an appointment with your gynecologist. Help spread awareness this month by sharing BEAT, and do your part to make sure these procedures are coded and billed correctly!
SGO website: Coding | Society of Gynecologic Oncology (sgo.org)