2020 OB/GYN SURGERY MEDICARE REIMBURSEMENT …

2020 OB/GYN SURGERY MEDICARE REIMBURSEMENT CODING GUIDE

Effective January 1, 2020

Medicare National Average Rates and Allowables

(Not Adjusted for Geography)

PHYSICIAN3

HOSPITAL OUTPATIENT4

ASC4

CPT? CODE1/ HCPCS CODE2

CODE DESCRIPTION

58150 58152 58180 58200 58210

58240

HYSTERECTOMY

Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s);

Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo-urethrocystopexy (eg, MarshallMarchetti-Krantz, Burch)

Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)

Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s)

Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s)

Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/ or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof

MEDICARE NAT'L AVG FACILITY SETTING

$1,056 $1,312 $1,005 $1,409 $1,890

$3,025

58260 Vaginal hysterectomy, for uterus 250 g or less;

$873

58262

Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)

$970

58263

Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele

$1,042

APC AND APC MEDICARE MEDICARE DESCRIPTION NAT'L AVG NAT'L AVG

Inpatient only, not reimbursed for hospital outpatient or ASC

Inpatient only, not reimbursed for hospital outpatient or ASC

Inpatient only, not reimbursed for hospital outpatient or ASC

Inpatient only, not reimbursed for hospital outpatient or ASC

Inpatient only, not reimbursed for hospital outpatient or ASC

Inpatient only, not reimbursed for hospital outpatient or ASC

5415, Level 5 Gynecologic Procedures

5415, Level 5 Gynecologic Procedures

5415, Level 5 Gynecologic Procedures

$4,272 $4,272 $4,272

$1,816

$1,816

N/A for ASC

PHYSICIAN3

HOSPITAL OUTPATIENT4

ASC4

CPT? CODE1/ HCPCS CODE2

CODE DESCRIPTION

HYSTERECTOMY (CONT'D)

58270

Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele

58275 Vaginal hysterectomy, with total or partial vaginectomy;

58280

Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele

58285 Vaginal hysterectomy, radical (Schauta type operation)

58290 Vaginal hysterectomy, for uterus greater than 250 g;

58291

Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

58292

Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele

58293

Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control

58294

Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele

58541 58542 58543 58544

58548

58550 58552 58553 58554 58570 58571

Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less;

Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g;

Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed

Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 g or less;

Laparoscopy surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g;

Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less;

Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

MEDICARE NAT'L AVG FACILITY SETTING

$932 $1,034 $1,109 $1,461 $1,208

$1,308

$1,379

$1,433

$1,279 $760 $865 $879 $947

$1,949

$924 $1,029 $1,180 $1,376 $830 $931

APC AND APC MEDICARE MEDICARE DESCRIPTION NAT'L AVG NAT'L AVG

5415, Level 5 Gynecologic $4,272 Procedures

N/A for ASC

Inpatient only, not reimbursed for hospital outpatient or ASC

Inpatient only, not reimbursed for hospital outpatient or ASC

Inpatient only, not reimbursed for hospital outpatient or ASC

5416, Level 6 Gynecologic $6,704 Procedures

N/A for ASC

5415, Level 5 Gynecologic $4,272 Procedures

N/A for ASC

5416, Level 6 Gynecologic $6,704 Procedures

N/A for ASC

Inpatient only, not reimbursed for hospital outpatient or ASC

5415, Level 5 Gynecologic Procedures

5361, Level 1 Laparoscopy

5362, Level 2 Laparoscopy

5362, Level 2 Laparoscopy

5362, Level 2 Laparoscopy

$4,272 $4,834 $8,413 $8,413 $8,413

N/A for ASC $2,194 $3,589 $3,589 $3,589

Inpatient only, not reimbursed for hospital outpatient or ASC

5361, Level 1 Laparoscopy

5362, Level 2 Laparoscopy

5362, Level 2 Laparoscopy

5362, Level 2 Laparoscopy

5362, Level 2 Laparoscopy

5362, Level 2 Laparoscopy

$4,834 $8,413 $8,413 $8,413 $8,413 $8,413

$2,194 $3,589 $3,589 $3,589 $3,589 $3,589

PHYSICIAN3

HOSPITAL OUTPATIENT4

ASC4

CPT? CODE1/ HCPCS CODE2

CODE DESCRIPTION

MEDICARE NAT'L AVG

FACILITY SETTING

APC AND APC DESCRIPTION

MEDICARE NAT'L AVG

MEDICARE NAT'L AVG

58572

Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g

$1,078

5362, Level 2 Laparoscopy

$8,413

$3,589

58573

Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)

$1,264

5362, Level 2 Laparoscopy

$8,413

$3,589

MYOMECTOMY

Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural 58545 myomas with total weight of 250 g or less and/or removal of surface $941

myomas

5361, Level 1 Laparoscopy

$4,834

$2,194

Laparoscopy, surgical, myomectomy, excision; 5 or more intramural 58546 myomas and/or intramural myomas with total weight greater than $1,173

250 g

5362, Level 2 Laparoscopy

$8,413

$3,589

OOPHORECTOMY

58920 Wedge resection or bisection of ovary, unilateral or bilateral

$744

5416, Level 6 Gynecologic $6,704 Procedures

N/A for ASC

58940 Oophorectomy, partial or total, unilateral or bilateral;

$565

Inpatient only, not reimbursed for hospital outpatient or ASC

58943

Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingectomy(s), with or without omentectomy

$1,216

Inpatient only, not reimbursed for hospital outpatient or ASC

58953

Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking;

$2,079

Inpatient only, not reimbursed for hospital outpatient or ASC

Bilateral salpingo-oophorectomy with omentectomy, total 58954 abdominal hysterectomy and radical dissection for debulking; with $2,253

pelvic lymphadenectomy and limited para-aortic lymphadenectomy

Inpatient only, not reimbursed for hospital outpatient or ASC

58956

Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy

$1,413

Inpatient only, not reimbursed for hospital outpatient or ASC

TUBAL LIGATION

58600

Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral

$385

5414, Level 4 Gynecologic $2,498 Procedures

$1,235

Ligation or transection of fallopian tube(s), abdominal or vaginal 58605 approach, postpartum, unilateral or bilateral, during same

hospitalization (separate procedure)

$348

Inpatient only, not reimbursed for hospital outpatient or ASC

Ligation or transection of fallopian tube(s) when done at the time

58611

of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary

$81

procedure)

Inpatient only, not reimbursed for hospital outpatient or ASC

58615

Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach

$261

5414, Level 4 Gynecologic $2,498 Procedures

$1,235

58670

Laparoscopy, surgical; with fulguration of oviducts (with or without transection)

$386

5361, Level 1 Laparoscopy

$4,834

$2,194

58671

Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring)

$385

5361, Level 1 Laparoscopy

$4,834

$2,194

ROBOTIC ASSISTANCE5

S2900

Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure)

N/A

References:

1. 2020 CPT? Professional Edition. American Medical Association. Copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

2. Centers for Medicare and Medicaid Services. Centers for Medicare & Medicaid Services. Alpha-numeric HCPCS. HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS-Items/2020-Alpha-Numeric-HCPCS-File

3. Centers for Medicare & Medicaid Services. Medicare Program; CY 2020 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Establishment of an Ambulance Data Collection System; Updates to the Quality Payment Program; Medicare Enrollment of Opioid Treatment Programs and Enhancements to Provider Enrollment Regulations Concerning Improper Prescribing and Patient Harm; and Amendments to Physician Self-Referral Law Advisory Opinion Regulations Final Rule; and Coding and Payment for Evaluation and Management, Observation and Provision of SelfAdministered Esketamine Interim Final Rule; Final Rule, Federal Register 84 Fed. Reg. No. 221 (62568-63563) 42 CFR Parts 403, 409, 410, 411, 414, 415, 416, 418, 424, 425, 489 and 498. Published November 15, 2019.

4. Centers for Medicare & Medicaid Services. Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Revisions of Organ Procurement Organizations Conditions of Coverage; Prior Authorization Process and Requirements for Certain Covered Outpatient Department Services; Potential Changes to the Laboratory Date of Service Policy; Changes to Grandfathered Children's Hospitals-Within-Hospitals; Notice of Closure of Two Teaching Hospitals and Opportunity To Apply for Available Slots. Final Rule, Federal Register (84 Fed. Reg. No. 218 61142 - 61492) 42 CFR Parts 405, 410, 412, 414, 416, 419, and 486. . Published November 12, 2019. Addendum B, AA. See also correction notice CMS-1717-CN; Addendum B, AA https:// d/2019-28364. Published January 3, 2020.

5. HCPCS II S-Codes cannot be reported to Medicare. They are used only by non-Medicare payers, which may cover and price them according to their own requirements

HOSPITAL INPATIENT PROCEDURE CODING FOR OB/GYN SURGERY

ICD-10-PCS procedure codes1 are used by hospitals to report surgeries and procedures performed in the inpatient setting.

All ICD-10-PCS codes have seven digits, each digit representing a specific character associated with procedures. Code assignment in ICD-10-PCS is a process of "constructing" the code by selecting values from a code table for each of the seven standard characters. Key characters are discussed below.

CHARACTER 3: Root Operation 4: Body Part 5: Approach

DESCRIPTION

The two main root operations for removal of tissue are B-Excision and T-Resection. By definition, B-Excision involves removing a portion of the body part and T-Resection involves removing the entire body part.2

For tubal ligation ie. sterilization, the root operation depends on the technique:

B-Excision is used for removal of a "knuckle" of the fallopian tube 5-Destruction is used for fulguration and cautery L-Occlusion is used for ligation and division as well as for placement of devices such as rings and clips

Note that physicians may use these terms more broadly. It is the coder's responsibility to determine what the physician's documentation equates to in terms of ICD-10-PCS definitions. The physician is not expected to document using ICD-10-PCS code descriptions.2

Because each body part is identified distinctly, separate codes are assigned for uterus (ie. corpus), cervix, ovary, and fallopian tube. This means that many common OB/GYN surgeries require two or more codes.

For example, ICD-10-PCS requires that two codes be assigned for a total hysterectomy: one removing the uterus and one code for removing the cervix. Similarly, for a total hysterectomy with bilateral salpingooophorectomy, four codes must be assigned: one each for removing the uterus, cervix, the ovaries and the fallopian tubes.

Different codes are constructed depending on the approach:

0-Open involves an open incision to directly expose the surgical site 4-Percutaneous Endoscopic is used for procedures performed via laparoscopy 7-Via Natural or Artificial Opening, eg. vaginal hysterectomy F-Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance, eg, laparoscopically assisted vaginal hysterectomy

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