Coding Q&A: OB or Backup Myoma Surgical Assist
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.
Is it possible to bill for 99360 as “backup” for surgeries?
When standby care is requested, both the requesting physician and providing physician must document the need for standby care. The standby doctor must not provide care to other patients during the standby period. This code is not used to report time spent proctoring another individual. It is also not used if the period of standby ends with the performance of a procedure subject to a surgical package by the individual who was on standby. This may not be reimbursed by carriers. Documentation such as noted below might be useful.
I was requested by [DOCTOR’S NAME] to be on standby for [PROCEDURE/INDICATION] performed on [PATIENT’S NAME] on [DATE]. I arrived at the operating room at [ARRIVAL TIME] and departed at [DEPARTURE TIME]. –
The patient was very adamant about not having a hysterectomy so our provider reconstructed the uterus and with the multiple myomas the surgery took 5 hours. Is there a code to reflect the additional time?
When a case exceeds the usual time/effort, the op note should reflect that and modifier 22 should be used. Case times vary, and there is not a code to denote “extra-long operative time”.
When using the 22 modifier, it is important to document fully why the work that was done above and beyond the normal scope. Simply stating it took longer will not justify additional payment.
Am I able to code 58558 and 58561 together or are these CPT codes bundled? The physician performed the D&C as well as polyp removal and hysteroscopic resection of myoma.
According to CCI these are bundled codes and may not be billed together. 58558: (Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C) is included when performed with 58561: (Laparoscopic/Hysteroscopic Procedures on the Corpus Uteri). A 59 modifier will not break the bundling. When a major surgery is performed laparoscopically/ endoscopically the minor procedure in that same site with the same entry and in the same session is considered an integral part of that major procedure and is not separately billable.
Is there specific documentation required in the op note to allow a nurse practitioner to bill for first assisting in the OR?
Surgeon should document assistant in the operative report. Assistant does not need to sign the operative report. For an assistant to bill in a teaching hospital it must be documented that no qualified resident was available or what exceptional medical circumstances existed to require the assistant. The assistant needs to bill the same surgical code as the surgeon, with either modifier -80 (Assistant Surgeon) or modifier AS (PA, NP or Clinical Nurse Specialist assistant in OR). Check with your regional carriers to determine which modifiers they recognize.
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