SGO Issues June 30, 2016


SGO Issues June 30, 2016

SGO responds to regulation implementing new physician payment system
TAH-BSO: How Would You Code?
Obstetrics & Gynecology seeks Gyn Onc Reviewers
Save the date: Winter Meeting call for abstracts
FWC webinar on post-surgical pain July 13

SGO responds to regulation implementing new physician payment system

On June 27, SGO sent a letter to the Centers for Medicare & Medicaid Services (CMS) regarding the implementation of the proposed rule for the “Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models” under the Medicare Access and Chip Reauthorization Act (MACRA). The letter, sent in response to the open comment period that closed on June 27, was specific to the subspecialty of gynecologic oncology. On June 24 SGO also signed on to a MACRA comment letter authored by the American Medical Association and co-signed by over 100 state, national, and specialty medical societies.

In effect since July 2015, MACRA, remained by CMS as the Quality Payment Program for physicians, repealed the Sustainable Growth Rate (SGR) Formula and streamlined multiple quality reporting programs into MIPS while also providing incentive payments for those that participate in Advanced APMs.

CMS is proposing several strategic goals in developing the Quality Payment Program including: (1) design a patient-centered approach to program development that leads to better, smarter, and healthier care; (2) develop a program that is meaningful, understandable, and flexible for participating clinicians; (3) design incentives that drive delivery system reform principles and participation in APMs; and (4) ensure close attention to CMS’ excellence in implementation, effective communication with stakeholders and operational feasibility.

According to the SGO comment letter, the Society has concerns that several of the proposals do not meet the program goals and principles laid out by CMS. SGO is urging CMS to:

  • Create a reporting option during the MIPS registration process that would allow for a specialty-specific group to self-designate as a “group,” under MIPS even if they are part of the Tax Identification Number for a larger facility practice plan or physician group.
  • Simplify the composite scoring system to enable a physician to look at their score and understand exactly how it was developed.
  • For the Advancing Care Information (ACI) Performance Category of MIPS, this entire section of activities needs to be simplified, made more flexible and lowered to a 90 day reporting period.
  • Create more opportunities for partial credit on the various elements and activities required under MIPS.
  • Make resource use meaningful to the diseases of gynecologic cancer and focus on including more sophisticated risk-adjustment, more sub-specialty comparison groups, and an improved attribution method.
  • For the APM option under the Quality Payment Program, re-work the definition/standard of “more than nominal risk,” and provide several examples using different types of alternative payment models to demonstrate how “more than nominal risk,” would be included as an element of the APM.
  • Reduce the number of proposed requirements for each MIPS category, delay the start date to July 1, 2017 and create an opportunity for physician practices to receive direct feedback from CMS on their proposed solutions for MIPS reporting or Advanced APM participation prior to the start date.

The letter also stated that “The SGO joins with its fellow medical societies in urging CMS to establish an initial transitional reporting period from July 1, 2017 – December 31, 2017 for the 2019 payment period. The MACRA law is very clear that the reporting period should be as close to the performance period as possible and CMS needs to use this flexibility to delay the start of the 2017 reporting period.”

TAH-BSO: How would you code?

A general gynecologist calls you in during an attempted total abdominal hysterectomy bilateral salpingo oophorectomy (TAH-BSO) to help identify the ureter and avoid an injury because of an unexpected broad ligament hematoma. The following description is how to code for the intraoperative consultation and subsequent procedure by the consulting gynecologic oncologist.

A consultation code may be used for the intraoperative consultation. Consultation codes have three key components: history, physical exam and medical decision making. The history is information obtained from the surgeon and perhaps from a brief review of the chart. The physical examination is that which is observed in the operating room and the medical decision making is the recommendation made to the operating physician.

As the history and physical examination are low level and typically problem-focused, the consultation code typically is a low level consultation, e.g., 99251 or 99252. If the patient is a Medicare patient the 9925X codes are no longer used, in which case the consultation code would typically be 99221. When the consulting physician also performs a portion of the operation itself, a -57 modifier is applied to the consultation code so it will be paid in addition to the procedure performed.

Coding for work performed at the time of the intraoperative consultation depends on the procedure performed. For example, if a ureterolysis is done to be certain that the ureter has not been injured and to avoid injury in addressing the hematoma, the best CPT code to use is retroperitoneal exploration 49010. (Note that although there are actually three ureterolysis codes in CPT, none of them applies to this scenario and ideally they should not be employed.)

On the other hand, if the anatomy is so distorted that the consulting physician actually has to complete the planned operation (a TAH in this scenario), the options include either coding for the retroperitoneal exploration alone with the operating physician coding for the hysterectomy or coding for the hysterectomy (58150) as co-surgeon (modifier -62) with the primary surgeon coding as the co-surgeon as well. In this case, the retroperitoneal dissection cannot be coded as the Correct Coding Initiative (CCI) bundles the 49010 with 58150 and accordingly one surgeon is precluded from using both codes on the same patient on the same date of service. In this scenario, the additional work of dissecting the ureter to avoid injury might justify using a complexity modifier (-22) along with the -62 modifier indicated above.

Submitted by Mike Berman, MD, SGO Task Force on Coding and Reimbursement

Download the complete coding Q&A to review over 100 questions and answers related to gynecologic oncology coding. Questions are submitted by SGO Members and their staff, recommendations are provided by members of the SGO Coding and Reimbursement Taskforce. Have a tough coding question? Email it to

Obstetrics & Gynecology seeks Gyn Onc Reviewers

Obstetrics & Gynecology, the official journal of the American College of Obstetricians and Gynecologists seeks reviewers active in the subspecialty of gynecologic oncology. Also known as the Green Journal, Obstetrics & Gynecology is a clinical journal that typically sends established reviewers three to four articles per year. All new reviewers need to send a request to register with the Green Journal’s editorial office by completing the form found on its Editorial Manager website. Fellows and junior faculty members who have not reviewed before are encouraged to apply. Completed forms can be returned to the editorial office by email to

Save the date: Winter Meeting call for abstracts

The call for abstracts for the 2017 SGO Winter Meeting opens Monday, Sept. 12, and closes Tuesday, Nov. 8. Abstracts will be reviewed during November. Authors of selected abstracts will be informed the week of Dec. 5, 2016. The next SGO Winter Meeting will be Jan. 26-28, 2017, at Beaver Run Resort in Breckenridge, CO.

FWC webinar on post-surgical pain July 13

The Foundation for Women’s Cancer is hosting a free patient webinar on Post-Surgical Pain Management Techniques, on Wednesday, July 13, from noon to 1 p.m. CT. The webinar will feature Sean Dowdy, MD, of the Mayo Clinic in Rochester, MN, and Pedro Ramirez, MD, of The University of Texas MD Anderson Cancer Center in Houston, TX. Preregistration is required.