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Coding Q&A: Ovarian Cancer or Masses

Coding ToolsAppendectomyDebulkingDiagnosis CodesFallopian TubeHysterectomyLaparoscopyMultiple or Difficult ProceduresNode Biopsy/LymphadenectomyOmentectomyOmentumOvaryPeritoneumProceduresSalpingo-oophorectomySurgery
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 ovarian cancer with cancers in both ovaries?

ICD-10 requires you to code to the greatest degree of specificity. If you have bilateral ovarian cancer, you should use BOTH the right ovarian cancer (C56.1) and the left ovarian cancer (C56.2) codes. The unspecified code (C56.9) might be appropriate for a patient diagnosed on biopsy if it is impossible to determine a site of origin.

 

Is it always necessary to identify the sites of advanced ovarian or fallopian tube cancer in ICD-10?

Yes, it is required for ICD-10 to identify the primary site of the tumor as well as sites of metastatic disease. Cancer codes for sites of metastatic disease are designated as “secondary cancer”. For example, a stage 4 ovarian cancer may be coded using 3 codes: C56.1 (malignant neoplasm of the right ovary), C78.6 (secondary malignancy of the peritoneum and retroperitoneum, and J91.0 (malignant pleural effusion).

 

How do you code for borderline ovarian tumors or tumors of low malignant potential? Should histology types (i.e., mucinous) be included in the coding?

Borderline ovarian tumors are “low malignant potential” not “no malignant potential”. There is therefore controversy about which code set to use.

The options are:

  • D39.1 Neoplasm of uncertain behavior of ovary
  • D39.10 Neoplasm of uncertain behavior of unspecified ovary
  • D39.11 Neoplasm of uncertain behavior of right ovary
  • D39.12 Neoplasm of uncertain behavior of left ovary
  • C56 Malignant neoplasm of ovary
  • C56.1 Malignant neoplasm of right ovary
  • C56.2 Malignant neoplasm of left ovary
  • C56.9 Malignant neoplasm of unspecified ovary

When using CPT codes that are designated for use for ovarian malignancies, e.g., 58950 (resection of ovarian malignancy with BSO and omentectomy) a cancer code should be used.

Histological types such as mucinous tumors are not included in ICD-10 codes. However, they are included in the ICD-Oncology codes. By and large, these are not needed for medical coding, but are important for tumor registries.

 

Is there a corresponding laparoscopic code for codes 58952 (Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (i.e., radical excision or destruction, intra-abdominal or retroperitoneal tumors) and 44955 (Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure) (List separately in addition to code for primary procedure)?

For a laparoscopic BSO with staging (for a patient with prior hysterectomy, for instance), you can use the CPT code 38573 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when performed) with a -22 modifier. That would be billed with the laparoscopic BSO CPT code 58661 with the -59 modifier for a second surgery. With any -22 modifier, you would need to have an operative note and letter requesting increased reimbursement with the rationale, in this case the extra time and effort for “debulking”.

For a laparoscopic appendectomy at the time of another procedure, the coding choice is code 44970 (laparoscopic surgical appendectomy). You will need to append modifier 59 to this code to indicate it is separate and distinct from the other surgery. The operative report documentation should clearly describe the procedure and the reason for performing it. You should also append a distinct ICD code, such as C78.5, secondary malignant neoplasm of the large bowel.

 

How do I code for a laparoscopic omentectomy done at the time of a laparoscopic BSO and pelvic and para-aortic lymph node dissection for a borderline tumor?

In 2018, the CPT code 38573 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when performed.) was created to address situation where a Gyn Onc is asked to perform staging where another surgeon has performed the laparoscopic BSO ± hysterectomy.

This code specifically excludes hysterectomy codes. If you perform a laparoscopic hysterectomy, BSO, debulking, the proper CPT code would be 58575 (Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed).

 

What is the most appropriate way to code laparoscopy with laparoscopic right salpingo-oophorectomy, left ovarian cystectomy, omentectomy and ovarian cancer peritoneal staging biopsies?<

Use code 38573 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when performed.) with a -52 modifier if not all of the components were performed. In addition, you can use laparoscopic BSO CPT code 58661 with the -59 modifier for a second surgery

 

How do you report a radical hysterectomy and bso without nodes; rectosigmoid resection; infragastric omentectomy; and optimal debulking on a patient with ovarian cancer?

The best approach is to report code 58953 (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking) plus the appropriate colectomy code (e.g., 44145) or other more appropriate code. If there was also a takedown of the splenic flexure, then you would also report code +44139 (Mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy). Code +44139 is not subject to multiple procedure reduction since it is an add-on code.

 

How do you code for a resection of a left ovarian CA; radical dissection and tumor reduction of pelvic tumor involving the rectosigmoid, mesentery and left pelvic retroperitoneal spaces; omentectomy; and pelvic and paraaortic lymphadenectomy on a patient with Stage III malignant germ cell tumor? The uterus and right ovary and tube were preserved.

You can use 58954 (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy) with modifier 52. The 52 modifier indicates a “reduced service” since the hysterectomy component was not performed. Not all payers recognize modifier 52 so that the full allowable amount may be reimbursed for the procedure. You can choose to decrease your fee as you deem appropriate. The appropriate colectomy code (e.g., 44145) should also be added to this procedure with a 59 modifier for multiple procedures.

 

How do you code for ovarian cancer staging for early disease? We perform a TAH/BSO, pelvic and para-aortic dissection, omentectomy, and biopsies?

The codes for ovarian cancer procedures are in the 58943-58958 for open procedures. The options for the above would be to code 58951 (Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy). If radical dissection for debulking is done, then you would report code 58954 (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy). Codes 58953-58956 can be used for cancer at all sites including the uterus. Although the selection of codes for treatment of gyn malignancy is fairly robust, there may be those occasions when the procedure actually performed is varied slightly from the available codes. In these instances, you can consider appending either a 52 (reduced services) or 22 (increased services) modifier to the basic procedure.

 

What code is best to use for an interval ovarian debulking surgery with TAH-BSO extensive pelvic dissection? There was no omentectomy or lymphadenectomy. Is it best to use 58150-22 (increased procedural services) or 58953? If I used 58953, would it be necessary to put a 52 reduced services modifier on it?

If there was described debulking of peritoneal implants, whether or not they turned out to be viable malignancy, use a debulking code- i.e., 58953. In the context of extensive debulking without omentectomy, it is reasonable to not reduce it with a 52. If there was just lysis of adhesions without debulking, then 58150-22 or 58956-52.

 

Would 58957 be the appropriate code for “total pelvic peritonectomy, other sites peritonectomy and diaphragmatic stripping” in ovarian cancer surgery?

Those procedures are included as “debulking”. 58957 is a code that is used for resection of recurrent gynecologic cancer. If you are doing a primary debulking then you should use 58952-58954 depending on what else is done.

 

Can I use 49205 for removing a large (>10cm) ovarian mass through a laparotomy incision?

49205 is not to be used in this circumstance. The procedure described is an oophorectomy and the code 58720 is the same regardless of the size of the ovary. If there is excessive work required it should be documented in the operative report and a modifier 22 may be added. The 4920X codes are used when managing masses not involving the uterus, cervix, fallopian tube or ovary.

 

Is it appropriate to append the 22 modifier to code 58210 when a total omentectomy is performed? Our practice has been unsuccessful in getting additional reimbursement from either Medicare or the commercial payers.

One of the problems lies in the fact that Medicare’s CCI bundles an omentectomy into code 58210 and will not allow it to be paid even with a modifier. Therefore, they may not be willing to pay additionally for the omentectomy even though the code does not include a total omentectomy. A number of other payers also use the CCI as part of the claims review process. You might try having the surgeon dictate a general letter indicating the need for the total omentectomy and the work involved including the additional time and risk. The letter should clearly indicate that the procedure is not a partial omentectomy. Another coding alternative might be code 58954 but this includes a debulking and assumes there is intra-abdominal disease.

 

What is the difference between codes 58950-58952 and codes 58953 and 58954?

The series 58950-58952 can only be used with ICD10 codes for ovarian, tubal or primary peritoneal malignancy. 58953-58954 may be used with any diagnosis. All describe various combinations of procedures commonly performed for advanced gynecologic cancers.

 

Is code 58720 bundled into code 49203?

Medicare’s Correct Coding Initiative (CCI) bundles 58720 into the payment for 49203 and does not allow it to be reported even with a modifier.

 

Can one report a radical debulking code (58952-58954) when there is no tumor outside the ovary?

No. Debulking codes are designed for when there is tumor outside of the ovary/fallopian tube/endometrium. If there is only staging performed, then the more appropriate codes are 58943 or 58950-58951.

 

What code is reported when a TAH/BSO/Omentectomy/Staging is performed for LMP or borderline tumor?

Code 58956 includes a TAH/BSO with total omentectomy. If this is the only staging performed, then this would be appropriate. A more likely choice would be code 58951, which includes a TAH/BSO, omentectomy, and P&P nodes.

 

How do I code for HIPEC for ovarian cancer?

There is no specific CPT code for intraoperative intraperitoneal heated chemotherapy administration. This procedure may be performed at the same surgical session following removal of all gross tumors from the abdominal cavity. Prior to completion of the surgical procedure, a warmed chemotherapy solution is administered directly into the abdominal cavity, allowed to dwell, and then drained while the patient is under general anesthesia. If the instillation of the hyperthermic chemotherapy solution is a planned, integral part of the surgical procedure, it may be reported with code 96549 (unlisted chemotherapy procedure), or alternatively with modifier -22 on the primary surgical code as the hyperthermic chemotherapy solution administration adds time to the surgical time and requires physician/operating suite staff work above and beyond that of the surgical procedure. CPT code 96446 is intended to report intraperitoneal chemotherapy administered through a permanently placed intraperitoneal catheter so is not appropriate for HIPEC.

 

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