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Coding Q&A: Cervical Cancer or EUA

Coding ToolsBiopsyCervixColon and Small BowelCystoscopyHysterectomyLaparoscopyMultiple or Difficult ProceduresNode Biopsy/LymphadenectomyNodesOvaryParametriumPelvisSalpingo-oophorectomySurgeryTrachelectomyUrinary TractVagina
Mar 15, 2021

Disclaimer: Answers to incoming questions are provided by the members of the Society of Gynecologic Oncology (SGO) Coding and Reimbursement subcommittee and represent their opinion based upon the current and usual practices in the field. Every effort is made to ensure the accuracy of the information provided. However, the information neither replaces information in Medicare regulations, the CPT-4 code book, or the ICD-10 CM code book; nor does it constitute legal advice. Responses to questions are intended only as a guide and are not a substitute for specific accounting or legal opinions. SGO expressly disclaims all responsibility and liability arising from use of, or reliance upon this information as a reference source, and assumes no responsibility or liability for any claims that may result directly or indirectly from use of this information, including, but not limited to, claims of Medicare or insurance fraud.

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How do you code for a radical parametrectomy?

Use a code for partial/total vaginectomy with removal of paravaginal tissue with or without nodes (codes 57107-57112)

 

How should you code for EUA/cystoscopy/proctoscopy for staging of cervical cancer?

EUA-57410. Cystoscopy (52000) and proctoscopy (45300) have separate procedure codes and are frequently not reimbursed when used with 57410 for a diagnosis of cervical cancer. However, if there is a separate diagnosis specific for cystoscopy or proctoscopy, (hematuria, melena, dysuria, constipation) you may use code(s) 52000 and/or 45300 linked with code 57410 using the 59 modifier.

 

What code do you use to charge for a Trucut needle biopsy of the pelvic soft tissue performed along with an exam under anesthesia?

Report code 20206 (Deep biopsy using percutaneous needle).

 

How do I code a robotic parametrectomy with lymph node dissection?

Use laparoscopic radical hysterectomy code (58548) with a -52 modifier for reduced work. You will have to provide documentation to explain.

 

How do you code for a radical abdominal hysterectomy and an ovarian suspension?

You should report code 58210 (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)) and 58825 (Transposition, ovary(s)).

 

How do you code for a radical hysterectomy when there was not a node dissection performed because the patient had pre-op radiation?

Report code 58210 with the reduced service modifier 52.

 

How do you code for a laparoscopic (robotic assisted) trachelectomy, BSO, and lymphadenectomy?

58548 with a reduced services modifier -52.

 

How would you code sentinel LN injection, mapping and resection with laparoscopic radical hysterectomy? 58548 includes PPA LND

55848 -52 reduced services if only the sentinel nodes were removed 38900 -50 intraoperative injection of dye for sentinel node identification. (Use modifier 50 for bilateral injections.)

 

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