Ob-gyn Coding: Simplify Endometrial Cancer Claims With These Three Steps

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Your coding for endometrial cancer surgeries can drastically transform if your ob-gyn converts a laparoscopic to an open procedure. Here are some tips that you can follow to stay away from denials.


Review this Op Note


Preoperative diagnosis: Adenocarcinoma of the endometrium


Postoperative diagnosis: Same, but greater than 50 percent percent myometrial invasion, pathology pending.


Operation carried out: Laparoscopic aided transvaginal hysterectomy (LAVH) with bilateral salpingo-oophorectomy, laparotomy with pelvic and periaortic node dissection, partial omentectomy, pelvic washings.


Process: Exam of the pelvic organs showed an eight-week-size uterus. The right as well as the left ovaries appear to be within normal limits. The ob-gyn did not find any evidence of excrescences or signs of metastatic disease in the lower pelvis along the bowel or serosa, nor did he find out evidence of metastatic disease in the upper abdomen, liver and dome of the diaphragm.


Then he removed the uterus ...
... vaginally with the help of the laparoscope, and the pathologist was present to open the organ and render an opinion.


The pathologist saw an enlarged, fungating, comparatively shallow lesion of the endometrium. However, up in the patient's right fundal area, the pathologist saw an invasion of the myometrium at least two-thirds of the way through. Considering this finding, the ob-gyn decided to carry out an open pelvic node dissection. He removed the laparoscope and made a new incision to enter the peritoneum.


He got hold of pelvic washings from the right cul-de-sac and pelvic area. He then carried out a partial omentectomy with the aid of multiple Kelly clamps.


The ob-gyn did a pelvic node dissection, initially on the right side identifying the ureter evenly. He carried down the dissection to include the internal and external iliac lymph nodes. Likewise, he carried out the same procedure on the left side. The dissection took place below the bifurcation of the aorta. The ob-gyn obtained tissue in the periaortic lymphatic chain area.


Step 1: Interpret the LAVH approach


The first thing you must do is make a decision whether your ob-gyn used two different surgical approaches - laparoscopic and abdominal.


Step 2: Clarify the Lymphadenectomy


The next challenge is to handle the "dissection" or lymph node sampling. The hitch is you are not aware the procedure was limited or complete. The dictation isn't clear.


You need to ask your ob-gyn to explain. To select the proper code, you must be aware whether your ob-gyn carried out a limited or complete pelvic lymphadenectomy.


Step 3: Tone down your Omentectomy Code


Contrary to the LAVH, your challenge for the omentectomy may be to alter an existing code to reflect the ob-gyn's "partial" work.


As per the op note, the ob-gyn performed a partial open omentectomy. Even though you have a code for the omentectomy, you don't have a code for a partial one. Under this situation you need to add modifier 52 (reduced services).


However, coding separately for the omentectomy for this surgical case may not be that straightforward. This is because your coding options change depending on which lymphadenectomy code you will be reporting. You may be aware that an omentectomy is not bundled with an LAVH or a complete lymphadenectomy; however you should consider it bundled when your ob-gyn carries out a limited lymphadenectomy. In the latter case, you cannot add modifier 59 to bypass the edit; as such your only option would be to add a modifier 22 (Increased procedural services) to code 38562 to account for the additional work. To put it in other words, if you bill 38770, you can bill 49255-52; if you bill a limited lymphadenectomy, you would bill 38562-22.


Pull everything together


Now that you have tackled these three challenges, you can report these codes together on your claim.


For more on this and for other specialty-specific articles to assist your Ob-gyn coding, sign up for a good medical coding resource like Coding Institute.