SGO Issues Dec 1, 2016


SGO Issues Dec. 1, 2016

How Would You Code? Endometrial Cancer Part 2: Lymphadenectomy
Continuous performance improvement | Marta Crispens, MD
Dr. Gardner explains why she is ‘All In’ to support research
Nominees named for HHS, CMS
AMA outlines health reform goals for new administration
Deadline extended to Dec. 9 for Claudia Cohen Research Foundation Prize

How Would You Code? Endometrial Cancer Part 2: Lymphadenectomy

There are a number of options for the type of hysterectomy and lymphadenectomy performed for the treatment of endometrial cancer. What are the correct codes for the various procedures that may be performed?

In the past, a single CPT code was available for the hysterectomy and lymphadenectomy. These were 58200 and 58210. With more widespread use of minimally invasive approaches for the surgical management of endometrial cancer, two CPT codes may be necessary, and several types of laparoscopic lymphadenectomy codes may be applicable.

When a bilateral pelvic lymphadenectomy is performed, CPT 38571 is appropriate. If an aortic node sampling is done in addition, then 38572 is appropriate. If done in conjunction with a hysterectomy then whichever lymphadenectomy code utilized requires the multiple procedure modifier 51, and will be reimbursed at 50%.

Recently, laparoscopic sentinel pelvic lymph node removal has become more frequent.  For this procedure, the coding for the hysterectomy is the same. However, for injection of the cervix with dye the CPT add on code 38900 should follow the CPT used for the type of lymphadenectomy performed. For a selective pelvic/aortic lymphadenectomy, the CPT code 38570 is applicable.

An example of billing for a laparoscopic hyst/bso/sentinel nodes is given below. The code with the highest RVU value should always be listed first.  For a selective lymphadenectomy the CPT code 38570 is applicable with the 51 modifier. The third code is an “add on” code and therefore doesn’t require the 51 modifier and should be reimbursed at the full wRVU listed.

Table II

Type of lymphadenectomy
Laparoscopic pelvic node dissection 38571 12 (14.76)
Laparoscopic pelvic and aortic node dissection 38572 15.6 (16.94)
Laparoscopy with retroperitoneal lymph node sampling (biopsy) (single or multiple) 38570 8.49 (9.34)
Identification of sentinel lymph nodes (includes injection of cervix) 38900 2.5 (2.5)
Example Laparoscopic hyst/bso/sentinel nodes for uterus less than 250gm 58571 15
38570-51 4.25**
38900 2.5
Total wRVU 21.75

2016 National Physician Fee Schedule Relative Value File January Release
2014 National Physician Fee Schedule Relative Value File January Release

Submitted by Brent DuBeshter, MD, at the University of Rochester in Rochester, NY.  Last month’s SGO Issues, “How Would You Code: Endometrial Cancer Part 1” focused on coding for hysterectomy

Continuous performance improvement | Marta Crispens, MD

Marta Crispens, MD

Marta Crispens, MD

The patient described here is fictitious, but is based on situations that we have all experienced.

Mrs. Smith is a delightful, 48-year old woman with stage IIIc high grade serous carcinoma of the ovary. She undergoes an optimal cytoreductive surgery, including modified posterior pelvic exenteration with low colon anastomosis. She is slender and healthy. The surgery goes well, except for some challenges with the colon anastomosis. In the end, it is airtight, and all seems well. She is discharged from the hospital quickly, but returns within 24 hours with a pelvic abscess due to a leak from her anastomosis.

Five months, multiple attempts at percutaneous drainage, weeks of antibiotics, a 13-hour operation, and an enterocuteous fistula later, she is discharged home again on TPN. It has reached the point that you dread going to her room, because you know that you will only have more bad news for her. Every time you see him, the husband fixes you with an angry stare. What we do is hard. It can eat your soul. You can tell yourself, “I did not give her the bad cancer,” as you turn and walk away, but it isn’t a satisfactory answer.

Peyton Manning, who played in the NFL for 18 seasons with the Indianapolis Colts and the Denver Broncos, is considered one of the greatest quarterbacks of all time. He holds the NFL record for passing yards, touchdown passes, career wins, AP MVP awards, and Pro Bowl appearances. He led his teams to two Super Bowl wins. Yet, Peyton Manning threw interceptions and lost games. How was he able to come back game after game and continue to play at such a high level, despite bad throws and bad games?

In sports psychology, it is recognized that fear of failure leads to poor performance. Successful athletes know that they will fail. They use their failures to identify their weaknesses and improve their performance. Peyton Manning was well known for his intense game preparation. He would spend hours watching game films, critiquing his own performance. He would then spend more hours out on the field, practicing with his teammates until they had the plays right. And then the next game, he would start the process over again—continuous performance improvement.

We are all going to have bad outcomes, but we cannot be consumed by them. Bad outcomes are not a judgment on us as people or as doctors. Self-abuse only interferes with your motivation and future performance. After the fact, we need to make an honest, dispassionate analysis of the situation. What can we do better the next time?

So you go back into that room, every day. And you tell the patient and her husband the truth, even though it is painful to them and to you. Then, you and your team non-judgmentally analyze the situation—what did we do right? What could we have done better? And every day, you are a better doctor for her and every other patient you care for. You identify your weaknesses and fix them, honing your skills day by day.

“True victory is victory over oneself.”
Morihei Ueshiba, O’Sensei
The Founder of Aikido

Marta Ann Crispens, MD, FACOG, is an Associate Professor and Director, Division of Gynecologic Oncology, in the Department of Ob/Gyn and Chair of the Vanderbilt-Ingram Cancer Center Scientific Review Committee at Vanderbilt University Medical Center in Nashville, TN.

Dr. Gardner explains why she is ‘All In’ to support research

Foundation for Women’s Cancer board member Ginger Gardner, MD, received an FWC Research Grant Award early in her career, which is why she is All In to support cancer research by young investigators. Supporters of the All In SGO development campaign can make a one-time donation or an annual commitment to the All In campaign to ensure that funding for gynecologic cancer research will be available for years to come.

Nominees named for HHS, CMS

On Nov. 29, President-Elect Donald Trump named Rep. Tom Price (R-GA), Chairman of the House Budget Committee, as his nominee for Secretary of Health and Human Services, and named Seema Verma as the Centers for Medicare & Medicaid Services (CMS) Administrator for the incoming administration.

A practicing orthopedic surgeon for nearly 20 years, Congressman Price was first elected to represent Georgia’s 6th district in November 2004. He is currently the chair of the House Budget Committee and was involved in the development of MACRA. His legislative record reflects a strong opposition to the Affordable Care Act (ACA) and he has been an active member of the GOP Doctors Caucus.

Seema Verma is the President, CEO and founder of SVC, Inc., a national health policy consulting company in Indianapolis. She is considered to be the “architect” of the Healthy Indiana Plan (HIP), which her company describes as “the nation’s first consumer directed Medicaid program,” under former Indiana Governor Mitch Daniels, as well as the HIP 2.0 waiver program under then-governor, current incoming Vice President Mike Pence. HIP 2.0 is the state’s alternative to traditional Medicaid expansion under the ACA.

SGO’s Health Policy and Socioeconomic Committee will be sharing more information regarding these individuals and their plans and ideas for HHS and CMS as they move through the confirmation process.

AMA outlines health reform goals for new administration

Citing the organization’s commitment to “improving health insurance coverage and health care access so that patients receive timely, high quality care, preventive services, medications and other necessary treatments,” on Nov. 15 the American Medical Association (AMA) outlined key elements of the association’s policy on health care reform that will be used in discussions with Congress and the incoming Trump Administration.

The main highlights of AMA’s health care reform policy are as follows:

  • Continue efforts to cover the uninsured, and ensure that any future proposals do not cause individuals covered as a result of Affordable Care Act (ACA) provisions to become uninsured.
  • Work to ensure that health insurance coverage actually translates to patients having access to the care and providers they need.
  • Improve health equity for minority, underserved and special needs populations.
  • Support including medical liability reforms consistent with policy.
  • Support the ability of patients to privately contract for medical services of their choice with no penalties.
  • Support graduate medical education funding consistent with extensive, long-standing policy.
  • Support reforms to the Medicaid and Medicare programs to ensure that they are viable and effective mechanisms to provide health insurance coverage to low-income individuals, seniors and the disabled.
  • Continue to promote market-based strategies to achieve the affordability of prescription drugs, and support initiatives to incentivize the pharmaceutical industry to exercise reasonable restraint in the pricing of drugs.
  • Advance initiatives that enhance practice efficiency and professional satisfaction, improve the delivery of health care, decrease administrative burdens of public and private insurance programs, and reduce health care spending.

Additional resources on the implementation of the Affordable Care Act are available on the AMA website.

Deadline extended to Dec. 9 for Claudia Cohen Research Foundation Prize

The application deadline for the Claudia Cohen Research Foundation Prize for Outstanding Gynecologic Cancer Researcher has been extended to Friday, Dec. 9, 2016. This $50,000 annual prize is awarded to an individual in recognition of his or her outstanding contributions to research improving the care of women with gynecologic cancer.