Avoid Ovarian Cyst CPT® Errors with 2 Helpful Tips

Look to the approach when you are preparing to code for ovarian cyst removal.

Coding for the removal/excision, aspiration of drainage of an ovarian cyst doesn’t have to be very difficult if you know the approach. The key is to pay attention to the approach, be it vaginal, abdominal (open) or laparoscopic.

Here are some vital tips that will help you get your claims right every time.

Choose the Correct Ovarian Cyst Codes

If the ob-gyn removes the cyst by cutting, you need to use (Ovarian cystectomy, unilateral or bilateral). However, for laparoscopic removal of an ovarian cyst, you need to choose the code based on the extent of the procedure. For example, when a laparoscopic ovarian cyst excision doesn’t involve the removal of any additional ovarian tissue, the right code for the procedure would be:

58662: (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method).

Sometimes cyst may turn out to be large and difficult to remove. In such cases, the ob-gyn may have to cut a part of the ovary at the same time. If so, you should use:

58661(Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]).

Tip: Documentation should measure up for medical necessity.

Cyst Aspiration May Include Ultrasound Guidance

To “aspirate” an ovarian cyst means that the ob-gyn removes fluids by way of a suction device. However, the terms “aspiration” and “drainage” are synonymous here. Select the code based on the method your ob-gyn uses to perform the aspiration.

If your physician aspirates ovarian cysts through an incision in the vaginal canal, use:

58800 (Drainage of ovarian cyst[s], unilateral or bilateral [separate procedure]; vaginal approach)

However if your physician aspirates through an abdominal incision, use:

58805 (… abdominal approach).

Again, for laparoscopic aspiration, use:

49322 (Laparoscopy, surgical; with aspiration of cavity or cyst [e.g., ovarian cyst] [single or multiple])

In cases where your ob-gyn needs to aspirate the cyst blindly through the skin or vaginal incision, he may need to use guidance. So if he takes the help of ultrasound guidance to place the needle that he uses to aspirate the cyst through the vaginal approach, you will probably use:

76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation).

In case the ob-gyn performs the actual aspiration under ultrasound guidance, you could also bill 76998 in place of 76942. Note that 76998 has a higher relative value than the latter.

Just as in all ultrasound guidance procedure, the ob-gyn is being paid for his explanation and the performance of the guidance procedure. Documentation must cover more than “procedure done under ultrasound guidance. These procedures also need permanently recorded images of the site to be localized along with a documented description of the localization process. This could be either separately or within the report of the procedure for which the guidance is used.