Gynecology

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 The AMA Manual’s CPT codes

Most of gynecology CPT codes are self explanatory, but some require comments.

Level II 88302

Fallopian Tube, Sterilization. Usually these specimens accompany a placenta after Cesarean section, but as in the Case # 6 they should be distinguished from a biopsy (Case # 4).

Vaginal Mucosa, Incidental (case #7)

Level III 88304

Bartholin’s Gland Cyst                                                        Hydatid of Morgagni

                                               Abortion induced

Level IV 88305

Abortion- Spontaneous/Missed

Endocervix, Curetting/Biopsy          Endometrium/Curettings/Biopsy

Polyp, Cervical/Endometrial Cervix Biopsy          Vagina biopsy  Vulva/Labia, Biopsy

                                               Fallopian Tube, Biopsy (very rare)

    Fallopian Tube, Ectopic Pregnancy Sometimes the specimen is defined in the requisition form as products of conception.

Ovary with or without Tube, Non-Neoplastic (Case # 6)

                                                  Ovary, Biopsy/Wedge Resection (Case # 5)

Uterus, with or without Tubes and Ovaries, for Prolapse (Case # 7)

Leiomyoma (s), Uterine Myomectomy-without Uterus

Placenta, Other than Third Trimester The requisition form should specify the term of pregnancy. The absence of this data can cause unintentional upcode. The third trimester spans from 28 weeks to the birth.

Level V 88307

Cervix, Conization  There are different description of this specimens in requisition forms as cervical cone biopsy; cervix cone; cervix, etc.  with or without suture orientation- a separate code if fragments in different containers)

Ovary with or without Tube, Neoplastic

Uterus, with or without Tubes and Ovaries, Other than Neoplastic/ Prolapse

Placenta, Third Trimester The third trimester spans from 28 weeks to the birth (see above in 88305)

Level VI 88309

Uterus, with or without Tubes and Ovaries, Neoplastic (Case #1)

Vulva, Total/Subtotal Resection (Case # 3)

Fetus, with Dissection A controversial specimen; there is a distinction between fetus as a surgical pathology specimen and autopsy by weight and weeks of gestation depending on the institution’s policy.

 

Suggested codes for unlisted in CPT Manual specimens in gynecology practice

Descriptor/code Comments
Adnexa-ovary with or   without tube, neoplastic/88307Adnexa-ovary with or   without tube, nonneoplastic/88305

Cervix amputation without   tumor/88305

Cervical cone/88307

Cervical cone biopsy/88307

Cervical cyst/polyp/88305

Cyst-dermoid, ovary/88307

Cyst – ovarian, neoplastic/88307

Cyst-ovarian, nonneoplastic/88305

Cyst-paratubal/88304

ECC (Endocervix,   Currettings/Biopsy)/88305

Ectopic pregnancy/88305

EMC (Endometrium,   Curretings/Biopsy)/88305

Endometrial polyp/88305

Fallopian tube cyst/88305

Fallopian tube – neoplastic/88305

Fibroid uterus/88307

Fistula/88304

Hymen/88305

LEEP  (Loop Electrosurgical Excision Procedure), biopsy/88307

Omentum resection – for   tumor/88307

Omentum resection –other   than for tumor/88304

 

Ovarian cyst – neoplastic/88307

Paratubal (peritubal) cyst/88304

POC (products of   conception) – induced abortion/88305

POC – spontaneous or missed   abortion/88305

Polyp – cervical or endometrial/88305

Surgical margin/88305

Uterine fibroids/88305

Vagina total or subtotal   resection/88309

 

Case #2 

 

 

rare, usually trauma

 

 

 

teratoma Case # 4

 

 

 

 

 

 

 

 

 

 

 

paratubal

separate procedure

vaginal

rare, usually girls

cervix conization

 

Case #1

Soft tissue debridement

 

 

 

 

separate procedure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The gynecology coding has some difficult situation also related to interpretation of lymph nodes procedures. There are some particularities in selected cases.

Case #1     TOTAL HYSTERECTOMY

A 58-year-old woman underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy due to endometrial cancer. The right adnexa were sent for frozen section. Regional lymph nodes were excided along with a fragment of omentum.

  Accession

 

S/# Specimen description CPT code
A Frozen section- right tube   and ovary 88331Level IV 88305
B Uterus & left tube   & ovary Level VI 88309
C Left pelvic lymph nodes Level V 88307
D Right pelvic lymph nodes Level V 88307
E Omentum Level VI 88307
F Periaorctic lymph node Level V 88307
G Left pelvic node biopsy Level IV 88305

The omentum description in the requisition form was inconclusive at the accession level (specimen E). In opposite to specimen G which is distinguished as a biopsy from specimen C that is by essence a regional resection.

The computer dictionary is usually designed for accession the frozen section specimens. If the frozen section specimen is not submitted entirely during procedure (specimen A), the rest is processes and coded accordingly the CPT descriptors, in this case as Level IV 88305 Ovary with or without Tube, Non-neoplastic. The immunoperoxidase stains for estrogen and progesterone receptors, as well as pankeratin and vimentin added in specimen B.

The final billing code after the pathologist’s report

S/# Specimen description CPT code
A Frozen section- right tube   and ovaryBenign ovary and fallopian   tube with hydrosalpinx and endosalpingiosis 88331;Level IV 88305; Level     IV 88305
B Uterus & left tube   & ovary- endometrial adenocarcinoma, tumor invades less than 50% of   myometrium; left ovary and fallopian tube no evidence of malignancy. Level VI 88309;88342 x4
C Left pelvic lymph nodes –   one lymph node 1.0×0.5×0.5 cm; no evidence of malignancy – yellow-tan adipose   tissue, no definite lymph node is identified; negative for malignancy Level V 88307
D Right pelvic lymph nodes-   adipose tissue 1.9x 1.8x 1.3 cm negative for malignancy Level V 88307
E Omentum- one fragment of   yellow-tan fibroadipose tissue (7.0×2.5×1.0 cm)-fragment of adipose tissue,   free of tumor Level V 88307
F Periaorctic lymph node –   two lymph nodes, free of tumor Level V 88307
G Left pelvic node biopsy- no   metastasis identified in two (1.0×1.0x0.4cm and 0.3×0.3×0.2 cm) examined   lymph nodes Level IV 88305

Omentum (specimen E) has only one taxonomy in the CPT manual, as Level IV 88305  Omentum, Biopsy. Some computer dictionaries, following the UMHS Finder List 88309-Omentum resection-for tumor and 88307 Omentum resection –other than for tumor. In this case, the specimen was larger than a regular biopsy, but not enough “big” for a usual omentum resection for tumor, however there was omentum resection. By the way, this case again demonstrates than amount of lymph nodes, never mind positive for tumor lymph nodes, do not determine Lymph Nodes, Regional Resection descriptor.

Case #2    Bilateral neoplastic adnexa surgery

A 68-year-old woman underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy with staging exploration due to adenocarcinoma of right ovary. There were frozen sections performed on right adnexa. There were 13 containers (1+ 12) sent to pathology.

Accession

 

 

S/# Specimen description CPT code
A Frozen section right addenda Frozen section Level IV   88305
B Uterus left tube and ovary Level VI 88309
C Left pelvic nodes Level V 88307
D Right pelvic lymph nodes Level V 88307
E Right pelvic lymph nodes #2 Level V 88307
F Paraaortic node Level V 88307
G Left pelvic wall Level IV 88305
H Right pelvic wall Level IV 88305
I Left gutter Level IV 88305
J Right gutter Level IV 88305
L Omentum Level VI 88309
M Diaphragm biopsy Level IV 88305

Level VI 88309 code added to specimen A because obviously the specimen has not been examined completely during the intraoperative consultation. However, specimen B was changed for Level V 88307 Uterus, with or without Tubes and Ovaries, Other than Neoplastic/Prolapse. Four immunoperoxidaxe stains were added for Smooth muscle actin, Desmin, Ki67, and P53 markers.

Final bill code

 

S/# Specimen description CPT code
A Frozen section right   salpingo-oophorectomy –moderately differentiated, endometrioid adenocarcinoma   focally involving ovarian capsule 88331Level IV 88305Level VI 88309
B Uterus left tube and ovary   Symplastic leiomyoma; Left ovary with focal endosalpingiosis. Acute and   chronic cervicitis Level V 8830788342 x 4
C Left pelvic nodes,   dissection- two benign lymph nodes Level V 88307
D Right pelvic lymph nodes,   dissection- one benign lymph node Level V 88307
E Right pelvic lymph nodes   #2, dissection – two benign lymph nodes Level V 88307
F Paraaortic node,   dissection- two benign lymph nodes Level V 88307
G Left pelvic wall, biopsy   –fibro-connective tissue, no evidence of malignancy Level IV 88305
H Right pelvic wall, biopsy-   fibro-connective tissue, no evidence of malignancy Level IV 88305
I Left gutter,   biopsy-fibro-connective tissue, no evidence of malignancy Level IV 88305
J Right gutter,   biopsy-fibro-connective tissues, no evidence of malignancy Level IV 88305
L Omentum, resection (510 gm,   20x15x6 cm) fibro- adipose tissue, no evidence of malignancy Level V 88307
M Diaphragm biopsy   –fibro-connective tissue with skeletal muscle, no evidence of malignancy Level IV 88305

Additionally, in specimen L (omentum) the code was changed for Level V 88307 as Omentum resection other than for tumor. See explanation in the case #1.

Case #3 Radical vulvectomy

A 71-year-old woman underwent a radical vulvectomy and bilateral lymphadenectomies due to vulvar cancer. There were sent to pathology eight containers.

Accession

 

S/# Specimen description CPT code
A Left sentinel blue hot node   deep Level V 88307
B Right superficial packet Level V 88307
C Separate right superficial   node Level V 88307
D Right deep lymph node Level V 88307
E Left superficial lymph node Level V 88307
F Left deep lymph node Level V 88307
G Radical vulvectomy Level VI 88309
H Deep left margin Level IV 88305

The final billing code after the pathologist’s report

 

S/# Specimen description CPT code
A Left sentinel blue hot node   deep; dissection- one lymph node with no evidence of malignancy; Pankeratin   immunostains were examined Level V 8830788342
B Right superficial packet,   dissection- ten lymph nodes with no evidence of malignancy Level V 88307
C Separate right superficial   node, dissection- one lymph node with metastatic carcinoma; tumor cells   positive for immunostain keratin Level V 8830788342
D Right deep lymph node,   dissection- benign fibroadipose tissue, no lymph node included in current   sample Level V 88307
E Left superficial lymph   node, dissection- three lymph nodes with no evidence of malignancy Level V 88307
F Left deep lymph node,   dissection- one lymph node with no evidence malignancy Level IV 88305
G Radical vulvectomy-   moderately differentiated squamous cell carcinoma, invasive into subcutaneous   and superficial muscle fibers; all surgical margins are free of invasive   carcinoma. Level VI 88309
H Deep left margin- adipose   tissue free of malignancy Level IV 88305

The billing manager downcoded the specimen F due to only one lymph node reviled in the specimen, but it is not correct because all B through F specimens are dissections.

Case # 4    Ovarian Teratoma

A 29-year-old woman underwent laporatomy with left ovarian cystectomy and bilateral fallopian tubes resection.

Accession

 

S/# Specimen description CPT code
A Left ovarian cystectomy Level IV 88305
B Left fallopian tube Level IV 88305
C Right fallopian tube Level IV 88305
D Intra Uterine Device Level I 883000

The final billing code after the pathologist’s report

 

 

S/# Specimen description CPT code
A Left ovary, cystectomy   –benign mature cystic teratoma (dermoid cyst) Level V 88307
B Left fallopian tube,   segmental resection- fallopian tube 1.1 x0.4 cm confirmed, completely   transected Level II 88302
C Right fallopian tube,   segmental resection- fallopian tube    0.9×0.4 cm confirmed, completely transected Level II 88302
D Intra Uterine Device   removal –T-shaped piece of plastic wrapped in wire coils consistent with IUD   gross examination only Level I 883000

 

Usually benign, dermoid cyst, or teratoma, is as a CPT code Level V 88307 Ovary with or without Tube, Neoplastic. The fallopian tubes were resected for sterilization owning the small trisection. The pathologist’s report considered them in this way. The billing manager correctly downcoded both specimens to Level II 88302 Fallopian Tube, Sterilization.

Case # 5    Asherman’s syndrome

A 36-year-old woman with Asherman’s syndrome underwent a laparoscopy and hysteroscopy. Fragments of both ovaries along with endometrial curettage material were sent to pathology.

Accession

 

S/# Specimen description CPT code
A Left ovarian cyst wall Level V 88307
B Right ovarian cyst wall Level V 88307
C Endometrial curettage Level IV 88305

 

 

The final billing code after the pathologist’s report

 

S/# Specimen description CPT code
A Left ovarian cyst wall   –fragment of benign ovarian parenchyma with focal endometriosis and signs of   old hemorrhage and adhesions Level IV 88305
B Right ovarian cyst wall-   fragments of benign ovarian parenchyma with focal endometriosis and signs of   old hemorrhage and adhesions Level IV 88305
C Endometrial curettage –   benign endometrial fragments with proliferative pattern Level IV 88305

 

The pathologist’s report confirmed the clinical diagnosis (Asherman’s syndrome). The surgery was by essence a biopsy and the billing manager correctly changed CPT coding for Level IV 88305 Ovary, Biopsy/Wedge Resection.

Case # 6   Adenoma ovary

A 46-year-old woman underwent an exploratory laparotomy with clinical diagnosis “Pelvic mass”.  A specimen labeled “left tube and ovary” was sent to pathology.

A frozen section was performed on a fragment of the cystic formation (310 gm, 11.9×7.4×6.7 cm).

Accession

S/# Specimen description CPT code
A Frozen section-left tube   and ovary 88331Level IV88305
B Pelvic lymph node Level V 88307

The final billing code after the pathologist’s report

 

S/# Specimen description CPT code
A Frozen section-left tube   and ovary- benign serous adenoma with recent hemorrhage and necrosis. No   malignancy identified. 88331Level IV 88305Level V 88307
B Pelvic lymph node – nodular   fragment of adipose tissue with fat necrosis, no lymph nodes identified. Level IV 88305

 

The Level V 88307 was added for additional, besides the frozen section, examination of the cyst that is Ovary with or without Tube, Neoplastic according to CPT coding manual’s taxonomy descriptor. The pelvic “lymph node” is a regular biopsy Level IV 88305.

Case # 7 Uterus prolapse

A 72-year-old woman underwent a hysterectomy with bilateral tubes and ovaries along with resection of fragments of vaginal mucosa.

Accession

 

S/# Specimen description CPT code
A Uterus, bilateral adnexa Level V 88307
B Vaginal mucosa Level IV 88305

 

The final billing code after the pathologist’s report

 

S/# Specimen description CPT code
A Uterus, total abdominal   hysterectomy, bilateral ovaries &tubes. Atrophic endometrium, leiomyomata   with calcification Level IV 8830588311
B Vaginal mucosa- fragments   of vagina mucosa-benign squamous epithelium Level II 88302

 

The hysterectomy for prolapse defined in CPT manual as Level IV 88305 Uterus, with or without Tubes and Ovaries, for Prolapse. The calcified leiomyomata, though definitely benign, required decalcification that has a separate code as 88311. Vaginal mucosa in this case was an incidental specimen that is Level II 88302 Vaginal Mucosa, Incidental.

Disclaimer

These materials do not represent official advice of the CAP, AMA, CMS or other governmental institution. The information will not bear any liability for its application and will not prevent any dispute with a third-party payer.

 

 

 

 

 

 

 

 

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