SGO Issues March 5, 2020
Article in press: Managing opioid use in the acute surgical setting
SGO Coding Corner: Coding for vulvar procedures | James J. Burke, II, MD
SGO founding member Leo Dunn 1931 – 2020
2020 SGO Resident Award now accepting nominations
Train the trainer webinar for HPV prevention
The current opioid crisis is relevant to gynecologic oncology patients in the acute surgical setting, and surgical pain management planning should include preoperative risk factor identification and postoperative pain education. According to an article in press in Gynecologic Oncology, “Managing opioid use in the acute surgical setting: A Society of Gynecologic Oncology clinical practice statement,” multimodal analgesia can achieve more effective pain relief, and clinicians should use restrictive opioid prescribing guidelines postoperatively whenever possible.
“In general, patients are aware of the opioid epidemic and appreciate the pre-emptive discussion about postoperative pain control,” said lead author Christine Kim, MD. “Many patients express their desire to avoid opioid dependence and some request avoiding these medications.”
Dr. Kim added that as a practitioner, one of the best strategies she has used to manage expectations of pain management with her patients has been to educate her patients preoperatively about the typical postoperative pain that is expected after surgery and how they can manage this acute postoperative pain after surgery.
“Patients are told that the goal is to provide adequate pain control while minimizing the risks and morbidities related to opioid use,” she said. “Patients are very receptive to receiving specific instructions such as how to use non-opioid pain medications like acetaminophen and ibuprofen on a regular basis and how they can incorporate alternative pain management techniques.
Dr. Kim noted that studies from the American College of Surgeons have found that 1 in 16 surgical patients prescribed opioids becomes a long-term user, and the risk for new persistent opioid use appears less associated with the surgical procedure itself than these known opioid risk factors.
“Some risk factors that raise my awareness that postoperative opioid misuse may occur include the patient’s history of alcohol and substance abuse, significant depression, anxiety, and preoperative pain disorders,” said Dr. Kim. “Being upfront with patients and setting realistic expectations for postoperative pain control goes a long way. Educating patients about potential side effects of opioids and describing various pain management options are important aspects of this. Some pain specialists are also willing to see patients deemed high risk for opioid abuse preoperatively.”
Addressing the opioid epidemic will require a collaborative approach between physicians, institutions, states and the federal government, Dr. Kim explained, adding that some institutions and surgical departments have their own guidelines for the number of opioid pills that should be prescribed based on the types of surgeries performed.
“Although almost every state has implemented a prescription drug monitoring program (PDMP) to some degree, this is not yet mandated by the federal Drug Enforcement Agency (DEA), nor is electronic prescribing for all schedule II and III medications,” she said. “In addition to mandating the use of electronic prescribing, increasing interstate’s sharing of prescription information would improve PDMP’s effectiveness.”
SGO’s Foundation for Women’s Cancer has produced a gynecologic cancer fact sheet for patients, “Postoperative Pain Management: Your Guide,” which covers pain management during a patient’s hospital stay and postoperative recovery at home.
Over the years treatment of vulvar diseases has changed dramatically. The treatment of pre-invasive disease has become less extensive and localized while the en block “longhorn” resection for treatment of carcinoma has been replaced by more localized radical excisions, with or without inguinal lymphadenectomy or sentinel lymph node biopsies. Several Current Procedural Terminology (CPT) codes exist to reflect the work of these procedures as well as complex wound closures. Below are several case vignettes illustrating coding for these vulvar procedures.
Case 1: The patient is a 41-year-old female with multi-focal (four separate lesions) VIN III. You treat the patient with CO2 laser destruction of the lesions. The most appropriate code for her treatment would be 56515, extensive destruction of vulvar lesions, any method, due to the number of lesions being treated. What is the difference between destruction of vulvar lesions, simple (CPT-56501) versus extensive (CPT-56515)? For these codes, CPT makes no reference as to what constitutes a simple treatment versus one that is extensive. In this scenario, the physician makes the determination and chooses the code he/she feels is most appropriate. 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 code selection. And of course, if you go with the extensive codes, be sure you document as completely as possible so that your choice of codes is clearly supported by your documentation.
Case 2: The patient is a 49-year-old female with extensive VIN III/CIS of the vulva encircling the posterior introitus (about 50% of the vulva). The patient is taken for a simple partial vulvectomy with split thickness skin grafting for coverage of 110 sq. cm. The appropriate vulvectomy code would be a simple, partial vulvectomy (CPT-56620) because less than 80% of the vulva is being removed. The procedure is a simple vulvectomy due to the depth of the resection; only the skin and immediate underlying subcutaneous tissue are removed. This procedure used to be called a “skinning vulvectomy.” Split-thickness skin grafting is completed by obtaining a skin autograft with a dermatome from a donor site (thighs, buttocks, abdomen, etc.) and is performed when direct wound closure or adjacent tissue transfer is not possible.
The billing is based upon the size of the defect to be covered in square centimeters (cm2); however, the dimensions of the donor site are NOT added to the size of the defect to be covered. In this example, the size of the defect is 110 square centimeters, the primary CPT code is 15120 and covers the first 100 cm2 or less. A secondary code is also billed (CPT-15121) which covers the additional 10 cm2 (up to a total of an additional 100 cm2). Since all of these CPT codes are affected by multiple procedure reduction guidelines, CPT 15120 code is listed first (wRVUs of 10.15), followed by the partial vulvectomy code (56620-wRVUs-3.77 [50% of 7.53]) and the secondary split thickness code (15121-wRVUs-1.00 [50% of 2.00]).
Case 3: A 68-year-old female has a biopsy proven, 2 cm, posterior fourchette, grade 2 squamous cell carcinoma of the vulva. She had a partial radical vulvectomy, bilateral inguinal sentinel lymph node biopsies and bilateral rhomboid flaps (each 4 x 4 cm) to close the posterior defect. To code this procedure, the most appropriate vulvectomy code is 56630, partial radical vulvectomy, since less than 80% of the vulva was removed. The code for sentinel lymph node biopsies is 38531 and is appended with the bilateral procedure modifier, -50. The intraoperative lymphatic mapping code, 38900+, is an add-on code to the primary lymph node biopsy CPT and also is appended with the bilateral modifier, -50 since injections for mapping were done on each side of the vulva. CPT codes that can be bilateral are billed once with the -50 modifier and are paid at 150% of the baseline wRVU of the code. Because the procedure is being done at the same session, but in bilateral locations, the pre- and post-operative care occurs one time for the patient. Hence the reason for the payment to be 150% of wRVUs for bilateral procedures.
The add-on code, 38900+, is a code that cannot be billed by itself and needs to be “added on” to a primary procedure, such as the lymph node biopsy code mentioned. Add-on codes are NOT subject to the multiple procedure reduction guidelines since they cannot stand alone as billable codes. The tissue transfer CPT is billed based upon the size of the defect to be covered. In this case it is 16 cm2 and the most appropriate CPT code is 14041 (adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet for a defect 10.1 cm2 to 30.0 cm2). This code is billed twice since the flap was developed from two different areas to cover the defect (both sides of the fourchette). A bilateral modifier (-50) is not appropriate (or necessary) for these procedures and the codes are valued at full value for each billable entry. However, these codes are subject to the multiple procedure reduction guidelines.
In this example, the vulvectomy code would be billed first (56630-wRVUs-14.8). Because the lymph node biopsy code (38531, modifier-50) is a bilateral code, it would firstly be valued at 10.11 wRVUs (which is 150% of 6.74 wRVUs of the base code). It would then be reduced as the second procedure (38531-wRVU 5.06 [50% of 10.11]). The lymphatic mapping would also be valued at 150%, but not reduced since it is an add-on code (38900+-wRVUs-3.75 [150% of 2.5]). Finally, the adjacent tissue transfer for 16 cm2 each, would be billed twice (14041-wRVUs-21.66 [10.83 x 2]), but would be reduced by 50% as the third procedure (14041-wRVUs-10.83 [50% of 21.66]).
Case 4: The patient is a 68-year-old with a biopsy proven, 3 cm, right labium majus, grade 1 squamous cell carcinoma of the vulva. She had a partial radical vulvectomy, right inguinal sentinel lymph node biopsies and a primary, complex wound closure of 9 cm. Again, the appropriate vulvectomy code is 56630, partial radical vulvectomy because less than 80% of the vulva was removed. The lymph node code and lymph node mapping code are as above, 38531 and 38900+, respectively. The first code listed would be the vulvectomy code (56630-wRVUs-14.8). The lymph node biopsy code is second (38531-wRVU-3.37 [50% of 6.74]), the lymphatic mapping code is an add-on code to the lymph node biopsy codes (38900+-wRVU-2.5 [no reduction due to being an add-on code]).
James J. Burke, II, MD is an Associate Professor at the Mercer University School of Medicine in Savannah, GA.
Leo J. Dunn, MD, MSHA, SGO founding member and longtime faculty member of Virginia Commonwealth University (VCU) died on Feb. 21 in Richmond, VA. According to his obituary in the Richmond Times-Dispatch, he was born on May 23, 1931 in Trenton, NJ and graduated from Hofstra University in 1952. After completing his MD degree in 1956 at the Columbia University College of Physicians and Surgeons, he completed his internship at Cincinnati General Hospital, then returned to Columbia to complete residency in Obstetrics and Gynecology. He joined the faculty of the University of Iowa in 1962.
In 1967, he was recruited as Professor and Chair to the Medical College of Virginia in Richmond (now Virginia Commonwealth University School of Medicine). He served as chair for 29 years, transforming a small group of clinicians into an academic department. After stepping down as chair, Dr. Dunn continued to be active on the faculty, serving as the NIH Research Subject Advocate for the Clinical Research Center until 2013. He also served as Interim Dean of VCU School of Medicine and initiated the OB GYN Nurse Practitioner Training Program.
Dr. Dunn had a truly remarkable career, serving in nearly all of the national leadership roles. He was President of the American Board of Obstetrics and Gynecologists and the American Gynecologic and Obstetric Society. A distinguished gynecologic oncologist, he was a founding member of the Society of Gynecologic Oncologists. A distinguished educator, he served as Chair of the Council of Resident Education in Obstetrics and Gynecology, President and Treasurer of the American Board of Medical Specialties, and Chair of the Accreditation Council on Graduate Medical Education. He also had leadership roles in the Society of Pelvic Surgeons, the American Gynecologic Society, and numerous societies and committees at the national, regional, and local levels. He was a prolific author, publishing papers not only in gynecologic oncology, but across the entire field of OB/GYN.
Dr. Dunn’s career was recognized with awards too numerous to list but notably included the Markle Scholar in Medical Science, Columbia University Outstanding Alumnus, and distinguished service awards from ACOG, MCV, VCU, ABMS, and ACGME.
Dr. Dunn left a tremendous legacy through his national leadership, the department he built in Richmond, the many patients he personally cared for, and the numerous students, residents, and faculty he trained and mentored. He is preceded in death by his loving wife, Beatrice Buchanan Dunn, in 2017. He is survived by his daughter, Laurie Melton, son, Dr. Cary L. Dunn, two grandsons, and one step grandson.
Submitted by David Chelmow, MD, Leo J Dunn Professor and Chair, VCU School of Medicine.
Nominations are open for the SGO annual Outstanding Resident in Gynecologic Oncology award. The award is for a single resident at each OBGYN program who best exemplifies the qualities of the mission and vision of SGO. The post graduate year (PGY) level of the recipient may be chosen by each individual program but should be consistent from year to year. Residency Program Directors and Coordinators are invited to use this nomination form to select one PGY resident from your program for this award. The nomination deadline is Thursday, April 9, 2020. Any questions can be directed to Traci Schwendner.
The National HPV Vaccination Roundtable is hosting a “train-the-trainer” webinar on the HPV Prevention: Nurses Get it Done toolkit on March 11 at 3:30 p.m. ET. This one-hour webinar will train nurses to use the Nurses Get it Done toolkit to teach the following:
- HPV 101 for Immunizers
- Messages for responding to common HPV vaccine questions
- Tips and resources for managing injection pain and shot aversion