Jan 08, 2020 · ICD-10-PCS Coding Example 0UT90ZZ, Resection of uterus, open approach (for the hysterectomy) 0UTC0ZZ, Resection of cervix, open approach (for removal of the cervix)
When ICD-10-PCS codes were first adopted, we were trained that to code a total hysterectomy appropriately would require two codes: one for the resection of the uterus, and one for the resection of the cervix. This followed the PCS guideline B3.2a which tells us that when the same root operation is performed on different body parts that have their own body part character we …
ICD-10-PCS Coding for Hysterectomy When coding the hysterectomy procedure in ICD-10-PCS, it is imperative that the operative report identify each body part removed (eg, uterus, cervix, fallopian tubes, ovaries). If a total hysterectomy is performed, the root operation will be resection, which is defined as the cutting out or off, without replacement, all of a body part.
A total hysterectomy includes the removal of both the uterus and cervix. ICD-10-PCS codes 0UJD4ZZ and 8E0W4CZ are assigned based on the following Character 5 root operation coding guidelines and advice for this procedure: Medical and Surgical Section of the 2015 ICD-10-PCS Official Guidelines for Coding and Reporting:
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.
January 16, 2012. Hysterectomy is the surgical removal of the uterus. It is one of the most common surgical procedures among women and is typically considered only after all other treatment options have been tried and failed. • Uterine fibroids (ICD-9-CM category 218): benign tumors of the uterus, which are also called leiomyoma, fibromyoma, ...
This open procedure is the most common approach for hysterectomy. • Vaginal: An incision is made in the vagina, and the uterus is removed through the vagina. • Laparoscopic: The hysterectomy is performed using a laparoscope and surgical tools inserted through the several small cuts in the body.
Alternatives to Hysterectomy. The following are potential alternatives to a hysterectomy: • Endometrial ablation for abnormal uterine bleeding (68 .23): laser surgery, which may be done through a hysteroscope, to remove fibroids. A dilation and curettage for endometrial ablation is also classified to code 68.23.
UFE may be performed with coils and is classified to code 68.24. The procedure may be performed by injecting other particles into the arteries, such as gelatin sponge, gelfoam, microspheres, polyvinyl alcohol, spherical embolics, or other particulate agent. Assign code 68.25 if the UFE is done without coils.
The ICD-10-PCS code assignment for this example is: 1 0UT90ZZ, Resection of uterus, open approach (for the hysterectomy) 2 0UTC0ZZ, Resection of cervix, open approach (for removal of the cervix) 3 0UJD4ZZ, Inspection of uterus and cervix, percutaneous endoscopic approach (for the attempted laparoscopic hysterectomy) 4 8E0W4CZ, Robotic assisted procedure of trunk region, percutaneous endoscopic approach (for the attempted robotic-assisted surgery)
In ICD-10-PCS, procedure codes consist of a seven character code structure, with each character code including specific values. ICD-10-PCS coding is applied at the procedure document type level where a code is assigned based on specific values for each of the seven characters (see Figure 1 above).
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.
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. If you know the approach and extent of the procedure, ...
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.
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.
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.