Coding Corner: Coding for Radical Hysterectomy | Leslie Bradford, MD
Scenario: I performed a radical abdominal hysterectomy with bilateral pelvic lymphadenectomy, but did not sample the paraaortic lymph nodes. How should I bill?
Scenario: I performed a radical abdominal hysterectomy with sentinel lymph node mapping and biopsy. How do I bill since I did a sentinel lymph node mapping and biopsy procedure rather than a full lymphadenectomy?
Answer: I have included two scenarios to highlight how coding for a radical hysterectomy is getting more complicated as the procedure evolves.
The CPT code for a radical abdominal hysterectomy is 58210. It includes 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). Every aspect of this CPT code must be met for your coders to bill appropriately. Thus, if you omitted the paraaortic lymph node sampling or performed a sentinel lymph node mapping and biopsy procedure rather than a full lymphadenectomy, you have not met all components of the 58210 CPT code.
Options are to apply a 52 modifier or to use a different CPT code. Modifier 52 is used to indicate partial reduction, cancellation, or discontinuation of services. Its use indicates a situation where a physician reduces or eliminates a portion of a service or procedure. It is important to know that using the 52 modifier may result in a 50% reduction in payment. Documentation of the procedure and knowledge of insurance policy is crucial. For instance, some insurers do not require any reduction in services whereas others ask you to report the percentage of the service performed, which is turn will determine the percentage of reduction in reimbursement (e.g. 75% rather than 50%). CPT 58210 generates 30.91 RVUs.
Alternatively, you can code as an extended hysterectomy, 58200. This does not capture the complexity of the radical hysterectomy, but does avoid the issue of not having performed a full lymphadenectomy, and results in 23.10 wRVUs (greater than the 58210 with a potential 50% reduction from the 52 modifier, but equivalent to the 58210 with a 52 modifier if your institution can argue for a lesser percentage of reduction in reimbursement). If performing a sentinel lymph node mapping and biopsy, you can include that CPT as well (38500).
Leslie Bradford, MD, is a gynecologic oncologist at Maine Medical Center in Scarborough, ME.