ICD-10-PCS Coding: Hysterectomy. When reading through documentation in an operative report for a hysterectomy, for the ‘Procedure Performed’, a ‘TAH-BSO, and Omenectomy’ is performed. As with all operative reports, there are guidelines that should be followed when determining the appropriate ICD-10-PCS codes. The first is identifying ‘TAH-BSO’.
The CPT® index, under the main term “hysterectomy,” lists your code choices according to the type of approach documented. This is your first step in selecting the right code.
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.
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, and the top part of the vagina.
722.
CPT® Code 58150 in section: Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)
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.
Excision of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach. ICD-10-PCS 0UB74ZZ is a specific/billable code that can be used to indicate a procedure.
Bilateral Salpingo-Oophorectomy refers to the surgical procedure in which both ovaries and fallopian tubes are removed from the body. Overall, Total Laparoscopic Hysterectomy with Bilateral Salpingo Oophorectomy is simply the surgical removal of the uterus, cervix, fallopian tubes and, ovaries.
0UT90ZZThe code for a total abdominal hysterectomy is: 0UT90ZZ Resection of uterus, open approach. In this example the “Z No Qualifier” is indicating that both the uterus and cervix are removed. The code for a laparoscopic supracervical hysterectomy is: 0UT94ZL Resection of uterus, percutaneous endoscopic, supracervical.
Vaginal hysterectomy is a procedure in which the uterus is surgically removed through the vagina. One or both ovaries and fallopian tubes may be removed during the procedure as well; removal of both ovaries and fallopian tubes is called bilateral salpingo-oophorectomy (BSO) (figure 1).
Your fallopian tubes are located on the top and on either side of your uterus, almost like a set of horns. When you have one fallopian tube removed, it's called a unilateral salpingectomy. However, if both fallopian tubes are removed, it's referred to as bilateral salpingectomy.
A bilateral salpingectomy is defined as the surgical excision of both fallopian tubes, up to the tubal corner of the uterus. The procedure can be implemented in several ways, for example during a hysterectomy (the removal of the uterus), a common treatment for both benign and malignant gynaecological conditions.
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.
1 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2020 edition of ICD-10-CM C54.
A total hysterectomy is the removal of the uterus and cervix. A total hysterectomy with bilateral salpingo-oophorectomy is the removal of the uterus, cervix, fallopian tubes (salpingo) and ovaries (oophor). A radical hysterectomy may be performed to treat cervical or uterine cancer.
double uterus (uterus didelphys) is a congenital uterine malformation resulting from the failure of the paramesonephric (Müllerian) ducts to fuse during embryologic development. The chapter talks about preoperative investigations, surgical route and incision, and operative technique required for the hysterectomy.
Laparoscopic Supracervical Hysterectomy. A laparoscopic supracervical hysterectomy is a minimally invasive procedure in which a woman's uterus, but not the cervix, is removed using a technique that involves several small abdominal incisions. It is one of the most common surgeries performed on women.
The other CPT code sets are the laparoscopy with vaginal hysterectomy (LAVH) (58550-58554) and laparoscopic supracervical hysterectomy (LSH) (58541–58544) code sets.
CPT 58571, Under Laparoscopic/Hysteroscopic Procedures on the Corpus Uteri. The Current Procedural Terminology (CPT) code 58571 as maintained by American Medical Association, is a medical procedural code under the range - Laparoscopic/Hysteroscopic Procedures on the Corpus Uteri.
The International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) is a U.S. cataloging system for procedural codes that track various health interventions taken by medical professionals.
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, ...
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.
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.
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).
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.
Although hysterectomy is a common procedure in gynecology practice, coding for it is a challenge due to so many code choices. Along with the surgical approach and extent (i.e., total or partial) of the hysterectomy, accounting for related performed procedures is key to code selection.
In CPT 2008, the American Medical Association (AMA) published the total laparoscopic hysterectomy (TLH) set of codes (58570-58573). This, in addition to the laparoscopic radical hysterectomy with pelvic lymphadenectomy code (58548), is the third set of CPT codes addressing the laparoscopic approach to hysterectomy.
LSH includes laparoscopically detaching the body of the uterus down to the uterine arteries. The uterine body is then separated from the cervix, hemostasis of the cervical stump is achieved, and the endocervical canal is coagulated. The uterine body is then abdominally removed by bivalving, coring, or morcellating, as required. ...