Q We plan to perform a laparoscopic right salpingo-oophorectomy and laparoscopic removal of the cervix. The patient had a previous laparoscopic supracervical hysterectomy and is now having abnormal bleeding and right lower quadrant pain. I know that the code for the RSO is 58661 (Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]), but how should we report the removal of the cervix?
A Although there is a CPT code for a trachelectomy (57530, Trachelectomy [cervicectomy], amputation of cervix [separate procedure]), this code cannot be reported because the procedure was performed laparoscopically. CPT rules dictate that correct coding would be an unlisted laparoscopic code.
This leaves you with 2 coding options. Because the cervix is part of the uterus, the code 58578 (Unlisted laparoscopy procedure, uterus) would be appropriate. If you choose this option, you would report 58661, 58578-51. Alternatively, you could add a modifier -22 (Unusual procedural services) to code 58661. Whichever option you choose, you will need to send documentation with the claim to explain the unlisted procedure or the additional work.
I prefer the first option because it will give you the opportunity to set your fee to account for the actual work performed.
Most payers will not deny unlisted procedures so long as they are not considered investigational or experimental, a concept that should not apply to this surgery.