Natalie Posted Sat 27th of June, 2020 10:16:42 AM
Surgeon did an exploratory laparotomy for a 16 cm complex pelvic mass. He performed a right salpingo-oopherectomy for the 16 cm. endometrioma (pathology was benign). He also found two ovarian cysts/endometriomas on the left ovary and did a left ovarian cystectomy. Then he removed several endometriosis implants from the uterus and the rectal serosa. Patient wanted to preserve fertility so he left the uterus and some of the left ovary intact. What is the best way to code these procedures? It was not an easy case.
SuperCoder Answered Mon 29th of June, 2020 09:33:39 AM
Thanks for your question.
Report the following codes:
- 58720 (Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)) for right salpingo-oophorectomy.
- 58925 (Ovarian cystectomy, unilateral or bilateral) for removal of cysts from left ovary.
- Removal of endometriosis implants is considered inclusive in the major procedure performed.
Please feel free to write if you have any question.
Natalie Posted Mon 29th of June, 2020 11:39:51 AM
Excision of lesions of the bowel and uterus can't be reported even if there were several large lesions and this was a good portion of the procedure and took at least an hour? It is the majority of the risk involved in the surgery. If the patient has complications it will be from the resection of the bowel serosa lesions. This is similar to a debulking from an ovarian cancer surgery.
SuperCoder Answered Tue 30th of June, 2020 08:00:56 AM
On occasions, the provider removes endometrial implants as well as ovarian cyst/s during the same surgery. If the provider documents significant additional work during this surgery, the addition of modifier 22 (Increased Procedural Services) requiring work substantially greater than typically required, may be an option.
If you think that the documentation is somewhat different, then we would request you to send more information from the medical record so that we may provide the exact codes.
Hope this helps.