SGO Coding and Reimbursement
SGO Coding and Reimbursement
Questions and Answers by Category
Answers to incoming questions are provided by members of the SGO Coding and Reimbursement Taskforce and represent their opinions based upon the current and usual practices in the field. Every effort is made to ensure the accuracy of the information provided. However, the information neither replaces information in Medicare regulations, the CPT-4 code book, the ICD-9 CM or the ICD-10 CM code book; nor does it constitute legal advice. Responses to questions are intended only as a guide and are not a substitute for specific accounting or legal opinions. SGO expressly disclaims all responsibility and liability arising from use of, or reliance upon this information as a reference source, and assumes no responsibility or liability for any claims that may result directly or indirectly from use of this information, including, but not limited to, claims of Medicare or insurance fraud.
References to ICD-9 codes are currently under review due to the transition to ICD-10.
Categories
BrachytherapyCervix
Chemotherapy
Evaluation and Management
Endometrial
Exenteration
Gastro-intestinal / ICD-10
Laparoscopy
Lymph Nodes
Modifier
Ovary
Vulva
Other
If you do not find the answer to your question here, please send an email to . Members of the SGO Coding and Reimbursement Taskforce alternate reviewing incoming inquiries and providing recommendations.
BRACHYTHERAPY1 / How do you code for the insertion of a Smit/cervical sleeve? / The SGO coding committee suggests that the insertion of the Smit sleeve be reported either using code 57800-22 (dilation of cervix) or 58120-52 (Dilatation and curettage). The 22 modifier indicates increased procedural service and the 52 denotes a reduced service. The 22 modifier will require a copy or the procedure note in order to obtain additional reimbursement for the increased work. Not all payers utilized modifier 52 when determining reimbursement so you may receive full payment even with the modifier.
2 / How do you code for placement of Heyman’s capsules? / Report code 58346 (Insertion of Heyman capsules for clinical brachytherapy).
3 / How do you code for placement of tandem/ovoids for brachytherapy? / Gyn oncologists should use code 57155 (insertion of uterine tandems and/or vaginal ovoids for clinical brachytherapy). Modifier 76 (repeat procedure by the same physician) may be necessary for subsequent treatments. Radiation oncologists will bill for insertion of radioactive elements using separate codes
4 / How do you bill for insertion of vaginal applicator device in High Dose Rate (HDR) brachytherapy? / The surgeon should use code 57155 (insertion of uterine tandems and/or vaginal ovoids for clinical brachytherapy) for insertion of tandem and ovoid. If a tandem is not placed, use a reduced service modifier 52.
5 / How does one bill for placement of fiducial markers/seed markers at the time of placement of a cervical/Smit sleeve for brachytherapy? / Use 57800, add -22 modifier.
This will require a copy of the procedure note to obtain additional reimbursement.
CERVIX
6 / How do you code for a radical parametrectomy? / Report a code from the series 57107-57111 (vaginectomy with removal of paravaginal tissue)
7 / How should you code for EUA/cystoscopy/proctoscopy for staging of cervical cancer? / EUA-57410. Cystoscopy (52000) and proctoscopy (45300) have separate procedure codes and are frequently not reimbursed when used with 57410 for a diagnosis of cervical cancer. However, if there is a separate diagnosis specific for cystoscopy or proctoscopy, (hematuria, melena, dysuria, constipation) you may use code(s) 52000 and/or 45300 linked with code 57410 using the 59 modifier.
8 / What code do you use to charge for a trucut needle biopsy of the pelvic soft tissue performed along with an exam under anesthesia? / Report code 20206 (Deep biopsy using percutaneous needle).
CHEMOTHERAPY
9 / We currently use Z58.11 for patients that are seen in the office, by their physician, prior to receiving chemotherapy at the hospital outpatient center. Is it correct to use Z51.11 with their E/M code when seen in the office? / You should routinely use the disease code (183, ovarian ca, for example) for an office visit, even if they are coming to be evaluated for chemotherapy. The patient is still being treated by the physician for the disease. You may also use Z51.11 as a secondary code if you are giving chemo in the office. This is so that drugs that are not obviously used for cancer like dexamethasone, ativan, etc, will be recognized as such.
If you are sending the patient to a hospital and not billing for chemo administration yourself, you should just report the disease code.
10 / We are getting denials for office visits reported on the same day as chemotherapy administration. The payer indicates that the visits are included in the global period of the surgery. Any suggestion on how to get the visits paid? / If the E/M service is for the purpose of evaluating the patient prior to chemotherapy or for counseling re: chemotherapy, then you would report the E/M service with the modifier 24. However, you may want to consider a diagnosis code other than the one used for surgery, such as the counseling code Z71.89 or a sign/symptom resulting from the chemo.
If the E/M service is primarily a post-operative visit, then it is not reported separately. Any evaluation re: chemotherapy would be included in that visit.
11 / Do we still use 96446 even if we do not perform the peritoneocentesis? Should we be adding the 52 modifier (reduced service)? / SGO has discussed this with the AMA and other applicable specialty societies. All agree that code 96446 is the most appropriate code to report IP chemotherapy. This code was created during the time when the standard of care required the testing of the patency of the catheter or fluid was sent for cytology prior to administering the chemotherapy. The language for the code descriptor was intended to prevent physicians from billing separately for the peritoneocentesis.
12 / What ICD code do you use for laboratory testing done on a day prior to chemotherapy administration? / You should always report the ICD code that most accurately reflects the reason for the service being provided. In your example, that would be the most specific code for the disease or the presenting sign or symptom. For example, if the patient has a low platelet/white count, then that should be used first followed by the cancer diagnosis. In the absence of a sign or symptom, then the cancer diagnosis should be primary. Code Z51.11 is specifically for the encounter at which chemotherapy is being provided.
13 / What code should be used to bill a port flush by a nurse in the absence of any other service? / If the patient is seen only for a port flush, code 96523 should be used. If you use a de-clotting or thrombolytic agent, you should use code 36550. Also remember to use the J-code for the specific thrombolytic agent used. The diagnosis code should be the patient’s primary cancer.
14 / When administering chemotherapy in an office setting, what are the requirements for the presence of the billing physician? / The physician is supposed to be “in the suite” as per Medicare rules. The interpretation of “in the suite” can vary for individual practices, but should generally mean under the same roof. It is fraudulent to bill for chemo administration if the physician is out of town, at the hospital, or otherwise out of the building.
15 / Is it sufficient for a Physician Assistant-Certified to be onsite in a clinic during a chemo infusion, or must a physician be physically onsite? / Generally speaking, NPs, PAs and non-oncology physicians can provide supervision for chemotherapy administration. You may want to clarify this with your individual Medicare carrier and other payers to make certain there are no local policies that contradict with this information.
16 / Can a gyn oncologist bill for chemotherapy counseling if that counseling falls within the global period following a surgical procedure? / Yes. Use the relevant E/M code with the 24 modifier for distinct E/M service during the global period. Also, you must use an ICD-10 code for counseling, such as Z71.89 (other specific counseling).
17 / The physicians are currently on the hospital floor when the chemo is being administered by the nursing staff at the hospital and want to start billing for chemo administration. I was asked to look into billing and I have not been able to find anything that would allow us to bill at a hospital if the nursing staff is employed by a different employer than the providers. Can you please clarify under what conditions providers can bill for chemo in a hospital setting? / Chemo administration codes require that the staff are your employees giving the chemo in your facility. If the doctor sees the patient at the hospital on the day of the chemo they could bill the appropriate E&M code but could not bill for the administration (i.e. 96365-96379 or 96401-96549). Chemotherapy administration codes reimburse primarily for the overhead/personnel costs of the infusion center.
You can only bill for chemotherapy administration if you own the facility. If it is a hospital–based infusion center, you cannot collect for chemo administration. However, the amount of physician work associated with most chemo admin codes is about 0.5 RVUs.
You can charge for E&M codes if they are separately identifiable services. You then must document what was done and show medical justification for the visit. It should not be duplicative of clinic visits.
EVALUATION AND MANAGEMENT
18 / Can you bill for inpatient and outpatient E/M services provided after surgery if the patient is seen for a post-operative complication such as a wound infection? Is a modifier required? / The CPT global surgical package includes all routine postoperative visits normally provided in conjunction with the surgery. Medicare includes in this, the treatment of complications managed outside the operating/procedure room. Medicare has set the global period as either 0, 10, or 90 days depending on the specific procedure. Most other payers follow Medicare's post-operative periods.
Most major gyn/onc procedures have a 90-day global period. Therefore, visits in the hospital immediately following surgery and routine outpatient visits are included in the payment for the applicable surgery and should not be separately reported.
E/M services for post-operative complications such as wound infections and dehiscence cannot be reported to Medicare until the patient is taken to the OR for a surgical procedure. Any procedure performed in the operating room associated with these conditions can be reported by appending modifier 78 (Unplanned procedure).
For non-Medicare payers, you can report any additional E/M services above routine care for services related to the surgery, such as wound infections. If visits for conditions unrelated to surgery are provided in the global period, these can be reported by appending modifier 24. Modifier 24 is used for E/M services provided in the global period that are "unrelated" to the surgery. No modifier is required for visits associated with complications or other related conditions.
19 / I heard that SGO suggests that all follow-up visits for cancer surveillance be reported using code 99214 for up to 5 years? / SGO does not make blanket suggestions about the level of service selection for specific types of E/M encounters. The level of service should be based on the CPT guidelines for selecting E/M codes and the work necessary to appropriately evaluate and manage the patient. The CMS Documentation Guidelines describe the documentation components for the various types of history, examination, and medical decision-making. Medicare and most private payers use these guidelines when reviewing medical records for levels of service. Note that CMS states, “Medical Necessity is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management (E/M) service when a lower level service is warranted.“
20 / How do you differentiate between a new patient and a consultation from another physician especially if I perform surgery and follow with chemotherapy? / According to CPT, a consultation is a type of evaluation and management service provided by a physician at the request of another physician (or appropriate source) to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem.
CPT further states you can initiate diagnostic or therapeutic services at that encounter or subsequent encounters and still report a consultation code. It is expected that the requesting provider will use the consultant's information in the care of the patient. This does not mean the referring physician has to provide all the f/up care for the condition but that the information was valuable to them as they continued to care for the patient.
If a provider is sending the patient to have a specific service provided and is not seeking input on a specific problem, then consultation codes are not used. For example, a patient is sent by an internist for a routine pap and pelvic exam. This is not a consult because there is no opinion being requested. A patient with a gynecologic cancer sent to you by a physician, may very well be reported using a consultation code. At that visit, you are likely making an independent evaluation of the best plan of care which may include surgery. Based on your evaluation, you will provide your written recommendations back (required to bill consult code) to the requesting physician. Once you have provided the initial consultation, subsequent services will be reported using the appropriate established patient codes or appropriate inpatient services.