Posted on 15. Jul, 2009 by in Hot Coding Topics
Coding for the removal/excision, aspiration, or drainage of an ovarian cyst doesn’t have to be rocket science, especially if you know the truth when it comes to 4 ovarian cyst coding myths.
When you’re preparing to code for ovarian cyst removal, you should pay particular attention to the approach, whether it is vaginal, abdominal (open), or laparoscopic, says Celia Hernandez, CPC, certified coder at South Haven Community Hospital in Mich.
For Laparoscopic Cysts, Look to Extent of Procedure
Myth #1: If your ob-gyn documents that he removed an ovarian cyst via a laparoscope, then you have all you need to choose what code to report.
Reality: For a laparoscopic removal of an ovarian cyst, you’ve got to dig deeper into your ob-gyn’s documentation and select the code based on the procedure’s extent:
• When a laparoscopic ovarian cyst excision does not involve the removal of any additional ovarian tissue, the correct procedure code is 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method).
• When the cyst is large and difficult to remove, the ob-gyn may have to remove part of the ovary at the same time. You should report this using 58661 (Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]).
Pitfall: If you look only at the CPT index under “cystectomy, ovarian, laparoscopic” you may be coding incorrectly, says Melanie Witt, RN, CPC, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M. CPT indicates that 58661 is the code you should use, but the surgeon’s documentation is the determining factor.
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