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Coding Q&A: MIS Surgery Specific

Coding ToolsCystoscopyDebulkingEpiosiotomyHysterectomyLaparoscopyMultiple or Difficult ProceduresOmentectomyOmentumPelvisSalpingo-oophorectomySurgeryUrinary TractUterusVagina
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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Is it permissible to report an open procedure code when there is not a corresponding laparoscopic code?

CPT guidelines indicate that it is not appropriate to report an open procedure code for a procedure performed laparoscopically. An unlisted code be reported when there is not a specific CPT code for the service provided. You will need to send in a special report or cover letter as well as the operative report to describe the need for the unlisted code.


Could you comment on the use of the S2900 code as an additional code for robotic surgery?

The “S” codes are HCPSC codes created by CMS and not CPT codes developed by the AMA. The recognition and utilization of these codes vary according to the payer. You would report code S2900 as a secondary code when you perform a surgery using robotics if required by your payers. It is not necessary to append a modifier. You should apply some incremental charge to the code for the work associated with the robotic approach that is different from the basic surgery you report. Reimbursement will vary by payer. CMS has made the decision not to have a modifier or specific codes for robotic surgery thereby restricting any additional payment for this technique.


Regarding billing for a gelport robotic assisted salpingo-oophorectomy; as this type of equipment requires a larger incision than other types of laparoscopy, can this procedure be billed as “open” vs “laparoscopic” CPT code?

The distinction between “open” and “laparoscopic” or “robotic” surgery is by what method the major portions of the procedure are done. In this case, if the adnexa is detached by robotic surgery but then an incision made to remove the specimen, the surgery is still “robotic”. The op-report should dictate the billing. Robotics is not billed any different than laparoscopy. Based on the fact that a robotic USO was done, it is recommended to submit a 58661 with a 22 modifier and submit the op report with it. It is not recommended to code this as an open procedure.


What code should be used to report a vaginal incision or episiotomy to deliver the uterus during laparoscopic/robotic hysterectomy?

This is bundled into the procedure and not separately billable, however you can add modifier -22 for increased work. Be sure to document the increased work in your operative note.


Is the 22-modifier appropriate if you convert from a laparoscopic to an open procedure with diagnosis code V64.41 (Laparoscopic surgical procedure converted to open procedure)? Does the operative report need to indicate additional time or just state that the procedure was converted?

No, you would only bill for the open procedure code. The 22 modifier is appended when the work to perform the procedure was substantially greater than that typically required. The conversion from laparoscopic to an open procedure might be an instance in which the 22 modifier is appended, but the documentation will need to reflect “substantial” additional work as specified in CPT. CPT also states that the reason for the additional work such be documented. It lists increased intensity, time, technical difficulty, severity of patient’s condition, and physical and mental effort as reasons for additional work. (See modifier 22 descriptor in Appendix A). The note does not specifically need to indicate additional time if any of the above reasons for the additional work is documented.


What is the difference between codes 58552 (Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s)) and 58571 (Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s))?

Codes 58550-58554 describe laparoscopically assisted vaginal hysterectomy which includes a laparoscopic detachment of ovarian vessels and skeletonization of the uterine attachments prior to performing the remainder of the surgery vaginally (colpotomy, division of parametria, closure of cuff). Codes 58570-58573 describe services in which the entire procedure is performed laparoscopically with or without robotics. In all of these procedures the specimen is removed via the vagina. The site of specimen delivery does not determine the code used.


Can you report a cystoscopy at the time of a pelvic procedure to make sure there is no injury to the ureters?

A cystoscopy performed routinely at the time of a surgical procedure is not separately reportable. When procedures are done to “check” one’s work, it is considered inherent in the procedure. If there is a separate indication, the ICD code can be appended to support a clinical need for the service, for example the presence of hematuria.


We have a provider that has started performing ureterolysis for retroperitoneal fibrosis. We know that CPT code 50715 is specific for this procedure/diagnosis our physician is performing the procedure laparoscopically and not open. Would you suggest reporting the ureterolysis with an unlisted or appending modifier 22 to the “main” laparoscopic procedure code?

CPT 50715 (ureterolysis for retroperitoneal fibrosis) describes an open procedure performed for a distinct diagnosis that’s also known as Ormond’s disease. The disease is characterized by excess fibrous tissue that develops in the retroperitoneal space behind the stomach and intestine. It is not meant to be used for ureterolysis performed due to post-inflammatory changes or postoperative adhesions. There is no analogous code for a laparoscopic approach and you should append modifier -22 to the main laparoscopic procedure. The increased work required should be clearly documented and quantified in the operative note.


Is there any decent code for the Robotic resection of presacral mass?

49215 is a laparotomy code for excision of a presacral mass. There is no corresponding laparoscopic code. Options include 49321 (laparoscopy with biopsy) and a 22 modifier with explanation of the extra work involved OR use of the unlisted code 49329 (unlisted laparoscopic procedure abdomen, peritoneum, omentum) with a letter recommending 49215 as the code most closely describing your procedure.


Is it appropriate to code 49321 when an omental biopsy is done during a laparoscopic hysterectomy, such as 58571?

If the omentum is removed without pathology it is generally not reimbursed. However, a biopsy of the omentum could be separately captured as CPT 49321 with modifier 59 if it was performed for a distinct diagnosis such as metastatic disease. The -59 modifier and separate diagnosis are required since 58571 and 49321 are bundled and trying to code both without it will run afoul of the CCI edits.


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