Coding Corner: Coding for Aborted Radical Hysterectomy | Stephen Bush II, MD
Gynecologic oncologists have all encountered situations where intraoperative conditions force them to change or abandon their surgical plans. Stephen Bush II, MD, a member of the SGO Coding Subcommittee, describes a coding situation which provides a great template for the thinking process behind a discontinued procedure.
A 25-year-old with a stage 1B2 squamous cell carcinoma of the cervix is scheduled for a radical abdominal hysterectomy with bilateral ovarian transposition. The procedure is started. The retroperitoneum is opened and an enlarged common iliac lymph node is sent for frozen section. While waiting for frozen results, the retroperitoneal spaces are further opened and explored. No other enlarged lymph nodes are found. The pathologist calls: squamous cell carcinoma is identified in the enlarged common iliac lymph node. The radical hysterectomy is aborted and the ovaries are transposed above the pelvic brim. The para aortic lymph nodes are removed.
58825: Ovarian Transposition (11.78 wRVU)
58210: Radical abdominal hysterectomy with bilateral total pelvic lymphadenectomy and para-aoritc lymph node sampling (biopsy), with or without removal of tube (s), with or without removal of ovary (s). (30.91 wRVU)
38562: Limited lymphadenectomy for staging; pelvic and para-aortic. (11.06 wRVU)
49010: Exploration, retroperitoneum with or without biopsy (s). (16.06 wRVU)
38770: Pelvic Lymphadenectomy, including external iliac, hypogastric, and obturator nodes. (14.06 wRVU) Can use modifier 50 for bilateral procedure which would yield (14.06 x150%= 21.09 wRVU).
38780: Retroperitoneal transabdominal lymphadenectomy, extensive, including pelic, aortic, and renal nodes. (17.7 wRVU). Cannot use bilateral modifier.
The best way to code this procedure would depend on the extent of lymphadenectomy performed. In the event a complete bilateral pelvic lymphadenectomy is performed the best code is 38770-50 (21.09 wRVU) in addition to 58225 (11.78 x 50% reduction = 5.89 wRVU) for a total of 26.98 wRVU. If only a few lymph nodes are removed the better code would be 49010 (16.06 wRVU) plus 58225 (5.89 wRVU after 2nd procedure reduction) for a total of 21.95 wRVU. One could also consider using 58210-52 or -53 for reduced or discontinued procedural services.
However, 52 or 53 modifiers will result in significant and sometimes unpredictable reduction in reimbursement. A52 modifier is used to report a serviced or procedure that is partially reduced or eliminated at the physician’s election. A53 modifier should be submitted with surgical codes or medical diagnostic codes when the procedure is discontinued because of extenuating circumstances after anesthesia is administered. For either code there should be good documentation of why the procedure was cancelled or aborted and the length/amount of procedure completed. Given other codes that more accurately describe procedure performed this may be unnecessary.
In addition to the above scenario 49010 may be a useful code for gynecologic oncologists to be familiar with when called to help a general OB/GYN colleague identify retroperitoneal anatomy.
Stephen Bush II, MD is a gynecologic oncologist at Charleston Area Medical Center/WVU Charleston in Charleston, WV.
SGO 2020 Coding Course Webinar Series
Evaluation and Management (E/M) codes will undergo their biggest change since 1992, effective Jan. 1, 2021. Stay ahead of the evolving reimbursement landscape with the two-part SGO 2020 Coding Course webinar series. Part 1 of this series, “Evaluation and Management Coding for 2021,” is scheduled for Wednesday, Sept. 16 at 7:00 p.m. CT / 8:00 p.m. ET. The webinar will be presented by Brad Hart, MBA, MS, CMPE, CPCP, CPMA, COBGC, from Reproductive Medicine Administrative Consulting, Inc. in Gastonia, NC, and moderated by Mary Cunningham, MD, from Upstate Medical University in Syracuse, NY. The second webinar, “Current Topics in Coding: Telehealth, Modifiers, Documenting Medical Decision Making,” is scheduled for Wednesday, Oct. 14 at 7:00 p.m. CT / 8:00 p.m. ET. The cost for the webinar series is $120 for SGO members and $150 for non-members. Office billing staff is welcome to attend. SGO is offering 3 hours of CE. Register now.