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Ob-Gyn Coding Alert

Reader Question:

Watch Your Modifiers for Follow-Up Care

Question: A different ob-gyn group operated on a patient, performing a total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. The patient had multiple postoperative complaints, including pain, cramping and fever. She came to my physician for a second opinion, and ended up in the hospital with fever and pain. My ob-gyn performed a laparoscopy and opened the vaginal cuff laparoscopically as a precaution for possible cellulitis and complaint of dyspareunia. He discovered a   2-cm mass in an old abdominal incision line. He converted the procedure to a laparotomy and found an abscess when he opened the old incision. How should I report this?

Kansas Subscriber Answer: From a diagnostic perspective, you should get more information from your physician before attempting to pick the correct CPT codes. Was the mass a tumor or a cyst, and was it removed? Or was the mass really an abscess? We also don't know if the physician drained the abscess during this session.
For the open procedure, then, you could choose from several coding possibilities, depending on the findings. You might pick 49020 (Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open) for the procedure's open part if the ob-gyn removed the mass as part of the new incision and drained the abscess.
Similarly, a payer may reimburse 49020 with 49200-51 (Excision or destruction, open, intra-abdominal or retroperitoneal tumors or cysts or endometriomas; multiple procedures) if the doctor excised the mass separately from the incisional line and drained the abscess. Both of these codes can be billed together, according to the National Correct Coding Initiative, version 9.2. The diagnosis codes will be the finding plus V64.4 (Laparoscopic surgical procedure converted to open procedure).
If you submit the claim to a private payer, you may also find additional reimbursement for laparoscopically opening the vaginal cuff by reporting 49329-59 (Unlisted laparoscopy procedure, abdomen, peritoneum and omentum; distinct procedural service). This procedure would be linked to 625.0 (Dyspareunia), but you can only code for cellulitis if the patient is confirmed to have it. 
If the carrier is Medicare or subscribes to Medicare's rules, however, you should report your open-procedure choice with modifier -22 (Unusual procedural services). You would append this modifier only to the highest-valued open-procedure code. In either case, be sure to submit the operative report and a letter explaining in lay terms the patient's condition and why it required the extra work.
You may be tempted to append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to the procedure(s) because another ob-gyn recently performed similar services for the patient, but don't. This modifier only applies to the original surgeon who is trying to bill for another procedure during [...]