HCPCS/CPT Code Short Description Comments
58611 Ligate oviduct(s) add-on Associated with a cesarean delivery.
58661 Laparoscopy remove adnexa
Only payable as a sterilization when the procedure is a salpingectomy when billed with diagnosis Z30.2 and *modifier FP. An oophorectomy is not payable when done only for the purpose of sterilization. *Modifier FP is needed only for billing under the Family Planning Only Pregnancy- Related and Family Planning Only programs.
CPT code DEFINITIONS:
Procedure Code 58661 – Endoscopic procedures fallopian tubes and/or ovaries with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy).
Procedure Code 58700 – Open procedures Fallopian Tubes, with/without ovaries salpingectomy, complete or partial, unilateral or bilateral (separate procedure).
Appendix C: Common reasons sterilization claims are denied
- A copy of the consent form is NOT attached.
- There are blank lines on the consent form. (All lines in sections I, II, and IV must be completed, except lines 21, 22, and 23 which are required only in certain cases.)
- Lines are not completed correctly on the consent form, or inaccurate information is included rather than what is needed.
- On the consent form, there are fewer than 30 days from the date of the client’s signature (line 8) to the date of the sterilization operation (line 19).
- The sterilization date on the consent form (line 19) is not the same as the sterilization date on the claim.
- The provider who signs the consent form (line 24) is not the provider listed on the claim as performing the sterilization procedure.
- The provider’s signature is illegible on the consent form and the provider’s name is not printed above his or her signature (line 24).
- The handwriting on the consent form is illegible or the photocopy quality is too poor to read.
- No expected date of delivery is listed with a premature delivery (line 22).
- The client consents to surgical sterilization and a hysteroscopic sterilization on the same consent form (tubal ligation and ESSURE).
- Salpingectomy (procedure code 58661 or 58700) is billed as a sterilization but tubal ligation is listed as the specific type of operation (line 20).
PURPOSE:
To define the indications for and authorization requirements for Endoscopic or Open Removal of Fallopian Tubes and/or Ovaries particularly associated with elective sterilization – Procedure codes 58661 and 58700.
GUIDELINE:
Partial or complete oophorectomy and/or salpingectomy (Procedure Codes 58661 and 58700), will require prior authorization for all indications.4 Bilateral tubal ligation (BTL) is a benefit under Texas Medicaid for sterilization under the appropriate circumstances.4 However, BTL accompanied by partial or complete oophorectomy and/or salpingectomy (Procedure Codes 58661 and 58700), in most instances, is considered experimental and investigational by evidence-based and American Academy of Obstetrics and Gynecology (ACOG) guidelines.
DHP will not consider a request for BTL with associated procedures 58661/58700 as quality concerns if the physician feels strongly and considers it a duty to his/her patient to offer the additional procedures without a clear indication, such as hereditary breast or ovarian cancer syndrome. However, DHP will request modification of the request, and authorize and pay as a BTL – codes 58670, 58671, and 58565. Additional payment for codes 58661/58700 will not be made.
Should the physician decline the modification then the procedure will be denied as experimental and investigational. Usual medical necessary appeal rights will be applied.
Documentation Requirements:
Clinical records documenting the medical condition (see ICD 10 codes below) as indication for procedure codes 58661/58700.
BACKGROUND:
Current evidence-based literature does not currently recommend routine partial or total salpingectomy (Codes 58661 and 58700) for elective sterilization procedures. 1, 3 However research suggests that in patients who have a genetic inclination to ovarian cancer that the risk of developing ovarian cancer is reduced if the tube is removed. The findings appear to show that ovarian cancer may originate from the fimbriated end of the tube. This data has been extrapolated to consider removing the tubes along with the uterus at hysterectomy if ovaries are to be preserved.
Interqual ® criteria for 58661 and 58700 include ectopic pregnancy, hereditary breast or ovarian cancer syndrome, hydrosalpinx or pyosalpinx, lynch II syndrome, tubo-ovarian abscess, torsion of ovary or ovarian cyst, ovarian cyst rupture, ovarian cyst or tumor. There is no indication to include these procedures for elective sterilization under these criteria.
Hydrodistention, cystoscopy: Why and what code?
- Can you enlighten me on therapeutic hydrodistention of the bladder: What is this for? What code would I use? A diagnostic cystoscopy was also performed.
ACystoscopy with hydrodistention, usually done as an outpatient procedure under regional or general anesthesia, is used to diagnose and sometimes treat interstitial cystitis.
During cystoscopy, the inside of the bladder is examined. Then the bladder is filled to a high pressure with fluid (hydrodistended). This causes the bladder wall to stretch, allowing the physician to inspect for changes typical of interstitial cystitis. Hydrodistention may reduce pain and discomfort in some interstitial cystitis patients, and thus may be therapeutic as well as diagnostic.
For this procedure, code either 52260 (Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction [spinal] anesthesia) or 52265 (… with local anesthesia). Be sure to verify the anesthesia type before billing for this service.
Low payment for cystectomy with oophorectomy
- My physician removed a patient’s ovaries and also performed a dilation and curettage. We coded these procedures as 58661 (Laparoscopy, surgical; with removal of adnexal structures [partial or total oophorectomy and/or salpingectomy]) and 58120-51 (Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]; multiple procedure), but received extremely low reimbursement.
The operative report stated extensive work was involved. An 8-cm ovarian cyst was excised, and some cystic fluid aspirated. Should we appeal? Also, should we have added modifier -22 (unusual procedural services) to 58661?
AFirst, keep in mind that payers always reduce the allowable on the second procedure performed, since they are paying for only the intraservice work, not the procedure’s entire global package.
Next: Code 58661 does not allow you to bill additionally for ovarian cyst removal or cystic fluid aspiration, because the physician also removed the ovary. However, there is 1 scenario in which additional reimbursement is possible.
An oophorectomy is by definition the removal of 1 ovary. For CPT codes in which oophorectomy is an integral part of the procedure (eg, total abdominal hysterectomy/bilateral salpingo-oophorectomy, open oophorectomy, open salpingo-oophorectomy) the language indicates whether they are used to report a partial or total unilateral or bilateral removal. Code 58661, however, only indicates “partial or total oophorectomy”—leading to the belief that it applies to only 1 side, not both.
If a physician removes the ovary on 1 side, but removes an ovarian cyst on the other, and if the payer agrees with this interpretation of the code, you might be able to bill both 58661 and 58662 (which covers both removal and aspiration of the ovarian cyst), placing the modifiers -RT (right side) and -LT (left side)
as appropriate. Still, many payers—including Medicare—do not agree with this interpretation and will not reimburse in this manner.
Your question, however, indicates that both ovaries were removed. Thus, additional reimbursement is unlikely.
Who Must Report?
All practitioners who are in groups, private-practices, multi-specialty practices or academic practice groups with 10 or more practitioners (“practitioner” includes both physicians and nonphysician practitioners) who provide 10- or 90- day global services in the nine states listed above are required to report post-operative visits starting July 1, 2017.
What Must be Reported?
Practitioners must report CPT code 99024 – Postoperative follow-up visit, normally included in the surgical package to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure – for every post-operative visit, inpatient and outpatient, they provide within the global period for a select list of 10- or 90-day global codes.
Reporting is required for all eligible practitioners, including physicians and non-physician practitioners, furnishing post-operative visits included in the global period regardless of whether or not the practitioner furnished the surgical procedure itself.
CMS created a list of 293 codes using the criteria of procedure codes reported annually by more than 100 practitioners and that are either reported more than 10,000 times or have allowed charges in excess of $10 million annually. To view the list of 293 codes, please visit the CMS website at: https://www.cms.gov/medicare/medicare-fee-for-servicepayment/physicianfeesched/global-surgery-data-collection-.html
SGO’s Coding Taskforce has reviewed the list and has identified the following three CPT codes as being relevant to SGO Members’ Practices:
CPT Code 58661 – Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
LAPAROSCOPY
58661 with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
EXCISION
58956 Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy
(Do not report 58956 in conjunction with 49255, 58150, 58180, 58262, 58263, 58550, 58661, 58700, 58720, 58900, 58925, 58940, 58957, 58958)
58661 – Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
AMA Guidelines
•Code 58661 describes a bilateral procedure, it would not be necessary to append Modifier 50 to indicate the procedure was performed bilaterally and it is not necessary to report modifier 52, Reduced Services for the removal of an ovary and/or fallopian tube on one side
CMS Guidelines
•CPT code 58661 has a status indicator of “1” in the Modifier -50 field indicating that a 150% payment adjustment applies for bilateral procedures
Empire is increasing its compliance with industry standards by adopting the following code combinations from the Center for Medicare and Medicaid Services (CMS) National Correct Coding
Initiative (CCI) into our payment policy.
The National Correct Coding Initiative is a collection of bundling edits that are separated into two major categories:
Comprehensive/Component Procedure Code edits and Mutually Exclusive Procedure Code edits.
Comprehensive/Component Procedure Code edits
Codes that are considered “Components” are incidental to the codes considered to be “Comprehensive” and will be denied as such. The table below lists the procedure that will be denied—”Deny Procedure”—as incidental to the corresponding “When Billed with Procedure.”
Mutually Exclusive Procedure Code edits
Mutually Exclusive Procedures are procedures that cannot be reasonably done in the same session.
To be consistent with existing payment policy, when Mutually Exclusive procedures are billed for the same date of service, only the procedure with the highest relative value (“When Billed with Procedure”) will be allowed and the procedure with the lower relative value (“Deny Procedure”) will be denied as Mutually Exclusive of the other procedure.
In some situations, according to CMS, certain modifiers may be allowed to bypass these edits.
Deny Procedure When Billed with Procedure
49320 58661
58661 58552
58661 58660
Coverage is subject to the terms, conditions, and limitations of an individual member’s programs or products and the edit criteria listed below. Please compare the claim’s date of adjudication to the range of the edit in question. Prior versions, if any, can be found below.
Description
CODE RULE CODE
58350 Separate Reimbursement 58661
58350 Incidental 58662
Rationale
Anthem Central Region does not bundle 58350 with 58661. Based on the National Correct Coding Initiative Edits, code 58350 is not listed as being a component code to code 58661. Therefore, if 58350 is submitted with 58661—both services reimburse separately Anthem Central Region bundles 58350 as incidental with 58662. Based on the National Correct Coding Initiative Edits, code 58350 was listed as a component code to code 58662 as of 1/1/2008. Therefore, if 58350 is submitted with 58662—only 58662
Description
This policy describes the medical necessity requirements for the removal of Essure®, a permanent birth control method that involves the bilateral placement of coils into the fallopian tubes which results in the development of scar tissue and occlusion of the fallopian tubes.
Policy/Criteria
I. It is the policy of Pennsylvania Health and Wellness® that the removal of Essure is medically necessary when meeting all of the following:
A. Member is having symptoms related to the device such as abdominal/pelvic pain or heavy/irregular menses not related to other gynecologic pathologies, device migration, or nickel allergy/hypersensitivity;
B. Performed by a gynecologist or surgeon experienced in removing the device;
C. Radiologic evaluation to determine the device location;
D. One of the following procedures:
- Hysteroscopy if = 7 weeks post-placement;
- Laparoscopy or laparotomy for one of the following:
a. Linear salpingotomy, salpingostomy, or salpingo-oophorectomy;
b. Cornual resection and repair;
c. Removal of devices that have migrated from the fallopian tubes.
Background
Essure is a form of permanent birth control that can be performed in an office setting and does not require incisions or general anesthesia. It involves the placement of spring-like devices into the proximal section of each fallopian tube via hysteroscopy. Over the next three months, scar tissue forms around the Essure coils facilitating insert retention and pregnancy prevention. The build-up of tissue creates a barrier to block sperm from reaching the eggs, preventing pregnancy.
Over the past several years, a growing number of adverse events have been report to the FDA (Food and Drug Administration) associated with the use of Essure. Frequently reported adverse events include pain/abdominal pain, menstrual irregularities, headache, fatigue, device migration, allergy/hypersensitivity reaction, and weight fluctuations. Because of these reported adverse events, there has been an increase in the number of women seeking removal of the Essure device.
Coding Implications
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2017, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to
the submission of claims for reimbursement of covered services.
CPT® Codes Description
58661 Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
Procedure Codes
58611
- CPT codes 58661 and 58700 represent procedures to treat medical conditions as well as for elective sterilizations. When filing paper claims for either of these services for elective sterilizations, enter type of service code “A”. When using either of these codes for treatment of a medical condition, type of service code “2” must be entered for the primary surgeon or type of service code “8” for an assistant surgeon.
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