Reimbursement Advisor

Coding etiquette for ‘shared’ surgeries


Q What is the correct way to code for “shared” surgeries? For example, Dr. A performed an exploratory laparotomy with bilateral salpingo-oophorectomy (BSO), during which he found cancer. Dr. B, a gynecologic oncologist, then performed bilateral pelvic/para-aortic lymph node dissection, peritoneal biopsies, omentectomy, and diaphragmatic scraping.

The diagnosis was serous papillary carcinoma. Dr. B wants to bill 58960 (second-look laparotomy) and 49255 (omentectomy) and have Dr. A bill for the BSO. Would this be accurate?

A Coding for shared surgeries is dictated by the procedures rather than who performed them. Many times, each surgeon will try to bill for his or her individual procedures without taking into account that CPT already may have codes that describe the combination of surgeries performed. In fact, a standard rule for coding is that if it is considered unbundling for 1 physician to itemize procedures described in a single procedure code, it would be considered unbundling for 2 surgeons to do so as well.

Coding for ‘shared’ surgeries is the dictated by the procedures rather than who performed them.

That said, Dr. B’s suggested coding choices would be incorrect. This is because the code for the second-look procedure includes an omentectomy and only a limited lymphadenectomy rather than a bilateral pelvic/para-aortic lymphadenectomy. In fact, none of the codes that apply to the treatment of ovarian cancer include a bilateral pelvic/para-aortic lymph node dissection procedure. Instead, they describe surgical combinations that comprise limited lymphadenectomy or biopsy.

To appropriately code for this particular combination of procedures, both physicians should report 59850-62 to indicate they were co-sur-geons for the bilateral salpingo-oophorectomy for ovarian cancer and omentectomy. In other words, 2 physicians worked together to accomplish distinct parts of a single reportable CPT code. Dr. B also should report code 38770-50-59. Code 38770 represents the pelvic/para-aortic lymph node dissection; the modifier-50 indicates that it was a bilateral procedure; and the modifier-59 states that the lymphadenectomy was distinct from the other procedures performed. If Dr. A assisted with the lymphadenectomy, he also should report code 38770 with the modifier-80 (assuming the surgery was not done on a Medicare patient because Medicare will not allow a physician who is billing as a primary surgeon to bill as an assistant during the same surgical session).

The second, less optimal coding option would be for Dr. A to report only the BSO using 58720 and Dr. B to code for the second-look procedure 58960-22 (unusual procedure). This method may delay payment for Dr. B due to the addition of the modifier-22 for the extra work required by the bilateral pelvic lymphadenectomy. Dr. A also may have difficulty obtaining reimbursement using this method; although he would be billing for a simple BSO, the procedure is linked to a code for cancer. Therefore, the payer may take a closer look at the procedure performed by both surgeons prior to payment.

Finally, the payment implications (using current Medicare relative value units [RVUs] for comparison) are different for these 2 options: The first will maximize reimbursement for Dr. B, while the second will do so for Dr. A.

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

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