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The other CPT® code sets are the LAVH (58550-58554) and laparoscopic supracervical hysterectomy (LSH) (58541–58544). Each of the code sets are subdivided into uteri less than or greater than 250 grams and with or without removal of tube (s) and/or ovary (s).
During many hysterectomies, although not listed in the ‘Procedures Performed’, the cervix or part of the cervix may be removed. When reading through the operative report, whether the cervix is partially excised or completely removed will determine ICD-10-PCS code selection.
Abdominal and vaginal hysterectomy (58152, 58263-58270, 58292-58294) include pelvic floor repairs to supporting structures that have prolapsed (i.e., weakened and “fallen”). To code prolapse repairs, the operative report should mention ligaments and supporting structures, approach for the procedure, and how the prolapse was repaired.
Total laparoscopic hysterectomy (TLH) – 58570-58575 – The laparoscope is used to detach the structures that can be removed through the vagina or through the trocars. The cuff is typically closed from above using trocars.
Acquired absence of both cervix and uterus The 2022 edition of ICD-10-CM Z90. 710 became effective on October 1, 2021.
Total Laparoscopic Hysterectomy (TLH) (Effective Jan. 1, 2008)CPT CodesUterine SizeTubes and/or Ovaries58570≤ 250 gramsNo58571≤ 250 gramsYes58572> 250 gramsNo58573> 250 gramsYes
Note the Difference Between LAVH and TLHTLH (effective Jan. 1, 2008)CPT® CodesUterine SizeRoute of Removal58570≤ 250 gramsTissues are removed through the abdomen or vagina58571≤ 250 gramsTissues are removed through the abdomen or vagina58572> 250 gramsTissues are removed through the abdomen or vagina1 more row•Oct 9, 2018
Acquired absence of uterus with remaining cervical stump Z90. 711 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM Z90. 711 became effective on October 1, 2021.
In 2018, the CPT code 38573 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when performed.)
58552 is a LAVH. Lap Assisted Vaginal Hysterectomy and the 58571 is for TLH, Total Laparoscopic Hysterectomy.
Definition: Total Laparoscopic Hysterectomy (TLH) is an operation to remove the uterus (womb) and cervix with the aid of a small operating telescope, called a laparoscope. The laparoscope is inserted into the abdominal wall through a small incision and allows the doctor to examine the pelvis/abdomen.
Listen to pronunciation. (sal-PIN-goh-oh-oh-foh-REK-toh-mee) Surgical removal of the fallopian tubes and ovaries. Enlarge.
Laparoscopic hysterectomy This allows the surgeon to see your internal organs. Instruments are then inserted through other small incisions in your abdomen or vagina to remove your womb, cervix and any other parts of your reproductive system. Laparoscopic hysterectomies are usually carried out under general anaesthetic.
In a total hysterectomy, the uterus and cervix are removed. In a total hysterectomy with salpingo-oophorectomy, (a) the uterus plus one (unilateral) ovary and fallopian tube are removed; or (b) the uterus plus both (bilateral) ovaries and fallopian tubes are removed.
(2008) , hysterectomies were defined using ICD-9-CM procedure codes 68.4, 68.5, or 68.9 in hospital discharge abstracts data.
Z98.51ICD-10 code Z98. 51 for Tubal ligation status is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
LAVH includes laparoscopically detaching the uterine body from the surrounding upper supporting structures. The vaginal portion of the procedure is then performed. The vaginal apex is entered, and the cervix and uterus are detached from the remaining supporting structures. The uterus is then removed through the vagina. TLH (effective Jan. 1, 2008)
An Asepto bulb was now placed vaginally to maintain pneumoperitoneum. The vaginal cuff was closed with figure of eight sutures of 2-0 PDS on either corner, and then running the cuff between the corners with 2-0 PDS. Both ureters were visualized, were peristalsing, and appeared to be of normal caliber.
The manipulator assists in providing a safe margin between the ureters and the vaginal fornices by pushing the uterus/vaginal/cervix away from these areas. The laparoscopic instruments are able to make the incisions around the vaginal area while staying away from the ureters and vaginal fornix.
In a TLH procedure, all structures are detached via the laparoscopic tools/incisions – the removal of the structures can be performed either via the laparoscopic incision or the vagina. A LAVH procedure does use a laparoscope, but it is used only for the initial part of the procedure as a guidance and visualization tool.
The surgical approach can be abdominal (the uterus is removed via an incision in the lower abdomen), vaginal (the uterus is removed via an incision in the vagina), or laparoscopic (procedure is performed using a laparoscope, inserted via several small incisions in the body).
Radical hysterectomy includes the removal of the entire uterus and nearby tissue, the cervix, and the top part of the vagina. If you know the approach and extent of the procedure, in some cases you may be able to determine the appropriate code without further detail. For example, an abdominal hysterectomy may be:
Mesh is used in both the anterior and posterior repair, but the anterior will overlap the mesh used for the sling. Modifier 59 can be reported for the posterior mesh because it’s a separate location. Example 2: Consider reporting for the following: Vaginal hysterectomy – 58260. Paravaginal defect repair – 57284.
There are three options: A total hysterectomy is the removal of the whole uterus, the fundus, and cervix. A subtotal, partial, or supracervical hysterectomy is the removal of the fundus or top portion of the uterus only, leaving the cervix in place. Radical hysterectomy includes the removal of the entire uterus and nearby tissue, the cervix, ...
First degree prolapse is incomplete and the uterus drops to the upper portion of the vagina. Second degree is also incomplete with the uterus dropping into the lower portion of the vagina. A complete or third-degree prolapse occurs when the uterus drops with the cervix to the vaginal opening.
CPT® coding for laparoscopic hysterectomy is based on the size of the uterus and the method used to complete the procedure. Documentation should state the weight of the uterus before it is sent to pathology.
Additional procedures performed during the same session — such as salpingo-oophoprectomy, pelvic floor repairs, or mid-urethral slings — may be bundled into the hysterectomy code. Consider each procedure when making the determination.
ICD-10 codes do not include the letters O (oh) or I (eye) as these are easily mistaken for the numbers 0 (zero) and 1 (one). ICD-10 code O UT90ZZ should be entered as 0 UT90ZZ and 0X6 I 0ZZ should be entered as 0X6 1 0ZZ.
The current list of operative procedure codes are found on the NHSN website in the “Supporting Materials” section of the Surgical Site Infection (SSI) Events web page.
The NHSN operative procedure code documents, posted on the NHSN site, are not intended to be instructive to medical coders for assigning procedure codes to surgical procedures.
NHSN operative procedure codes are reviewed and updated annually and as needed.
The use of the NHSN operative procedure codes (ICD-10-PCS or CPT) is required to determine the correct NHSN operative procedure category but entering the operative procedure code into the NHSN application remains optional.
If a procedure is assigned a procedure code with an open approach and a procedure code with a scope approach then the procedure should be reported to NHSN as Scope = NO. The Open Approach indicates a higher risk.
Within the ICD-9 code system there were specific revision codes for procedures that involved distal shunt replacement or revision of the distal catheter, there are no codes within the ICD-10-PCS code system that are specific for this type of procedure.
If you look up ovarian cystectomy in the index of CPT, you are referred to code 58661 for that portion of the procedure also. The code cannot be reported with the bilateral modifier, which means that although procedures were done on the right and left sides, this code includes both procedures.
When a pelvic examination is performed in conjunction with a gynecologic procedure, either as a necessary part of the procedure or as a confirmatory examination, the pelvic examina tion is not separately reportable. A diagnostic pelvic examination may be performed for the purpose of deciding toperform a procedure.
Based on American College of Obstetricians and Gynecologists, it states “Services that cannot be reported with 58661 under any circumstances- Lysis of adhesions (44005, 44180, 58660 and 58740)”. Therefore, if code 58740 is submitted with code 58661 only 58661 will reimburse.