Coding Q&A: Endometrial Cancer

Disclaimer: Answers to incoming questions are provided by the members of the Society of Gynecologic Oncology (SGO) Coding and Reimbursement subcommittee and represent their opinion 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, 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.

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What is the code for laparoscopic or robotic endometrial cancer surgery with hysterectomy and BSO with pelvic and para-aortic lymphadenectomy?

You would code the hysterectomy (58571 or 58573) and lymph nodes separately (38572-51) If the uterus was > 250gm then 58573 should be used, and laparoscopic pelvic lymph node resection only is 38571, and with para-aortic nodes is 38572.

Sentinel node mapping would use 38900 -50 for bilateral injection of dye and 38570 for node biopsy. If full node dissection needs to be done because of non-mapping or some other reason you can still bill the 38900-50 if the injection was done.

How do you code for a laparotomy with pelvic and para-aortic lymphadenectomy and omentectomy for endometrial cancer when a TAH/BSO was done by the Ob/Gyn?

When 2 surgeons perform procedures that are all included in one code, they should both use that code and split as co-surgeons. In this case each would bill 58210 for TAHBSO with pelvic and para-aortic lymphadenectomy with modifier 62 for 2 surgeons. Omentectomy without pathology is generally not reimbursed.

What is the correct way to code a TAH/BSO with omentectomy and full staging for a diagnosis of papillary serous endometrial carcinoma?

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If there is no gross metastatic disease then use 58210 for TAHBSO, pelvic and paraaortic nodes. Omentectomy without metastatic disease is generally not reimbursed. If there is gross disease in the omentum then could bill 59854 (TAHBSO, pelvic and paraaortic nodes, omentectomy and debulking) as this code is for any malignancy.

How do you code for IUD placement for endometrial hyperplasia or cancer?

58300 is the CPT. The ICD10 code is Z30.430. The patient’s diagnosis code may or may not make a difference to the insurer since this is an off-label use. If they are reproductive age you could present this also as contraception device.

How do you code for laparoscopic/robotic sentinel lymph node biopsy(ies) in endometrial and cervical carcinoma?

The code depends on dye injected. For non-radioactive dye use 38900, with modifier 50 if bilateral mapping is performed. In addition, bill the appropriate laparoscopic lymph node sampling or lymphadenectomy code depending on the extent and location of the dissection. If lymph node dissection is done because of non-mapping or other indications such as lymph adenectomy then the 38900-50 can still be billed with the lymphadenectomy codes.

How do you determine the difference between node sampling, biopsy, dissection and lymphadenectomy?

“Node dissection” and “lymphadenectomy” are often used interchangeably and usually this means that the entire nodal bundles are removed rather than a few isolated nodes. Remember not to unbundle; if nodes are removed at the time of open hysterectomy they will be coded together. The following apply when the node procedures are not already bundled into the code:

For open procedures, options are:

• 38562 – Limited lymphadenectomy for staging; pelvic and para-aortic. This would be appropriate for a situation in which only a few selected nodes were removed without performing a full lymphadenectomy. i.e., sentinel lymph node(s) or isolated enlarged lymph nodes.
• 38770 – Pelvic lymphadenectomy including external iliac and obturator nodes. If bilateral use modifier 50.
• 38780 – Retroperitoneal lymphadenectomy, extensive. Includes pelvic and paraaortic and infrarenal nodes

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For laparoscopic procedures:

• 38570 – Retroperitoneal lymph node sampling. (This would apply to a situation where only a few isolated nodes are removed. i.e., sentinel lymph node(s) or isolated enlarged node(s)
• 38571 – Total pelvic lymphadenectomy
• 38572 – Total pelvic lymphadenectomy with paraaortic node sampling

What code would you report for the removal of 2 large pelvic nodes at the time of a TAH/BSO on a patient with post-menopausal bleeding? The nodes were benign.

58200 is the code for TAHBSO with PA and Pelvic node sampling. The number of nodes and pathology report do not impact the use of this code.

Is CPT 38900 still a billable service for the work performed when there are no sentinel nodes identified for biopsy? The patient had a total laparoscopic hysterectomy, bilateral salpingo-oorphorectomy in addition for endometrioid endometrial adenocarcinoma.

Lymph node mapping (38900) must be added on to a code for removal of nodes, whether sentinel nodes or full lymphadenectomy. If no nodes are removed then 38900 may not be billed.

Is there a certain percentage of myometrial invasion of endometrial cancer that would warrant the use of C54.8 as opposed to C54.1 endometrial cancer? If we have ovarian cancer of the same type in both ovaries, should we use C56.1 along with C56.2 or should we use a single code such as C57.8?

Code for primary site of origin: if it is an endometrial cancer with myometrial invasion the site of origin is the endometrium (C54.1). If there are metastases to the ovaries use the code for secondary malignancy of the ovaries C79.60. If one or both ovaries contain a separate primary then use the primary ovarian cancer codes for right ovarian cancer (C56.1), left ovarian cancer (C56.2) or both if bilateral.

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