722.
Z90. 710 - Acquired absence of both cervix and uterus | ICD-10-CM.
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.
The 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.
The best approach is to report code 58953 (Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking) plus the appropriate colectomy code (e.g., 44145) or other more appropriate code.
Total abdominal hysterectomy (TAH) is removal of the uterus including the cervix (lower portion of the uterus). Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) is removal of the uterus, cervix and both fallopian tubes and ovaries.
Overall, Total Laparoscopic Hysterectomy with Bilateral Salpingo Oophorectomy is simply the surgical removal of the uterus, cervix, fallopian tubes and, ovaries.
Hysterectomy removes all or part of the internal reproductive organ (uterus) and sometimes the gonads (ovaries), internal reproductive organ (fallopian) and internal organ (cervix). Oophorectomy removes one or both of the gonads (ovaries).
The side-effects of undergoing hysterectomy with bilateral salpingo-oophorectomy may include: Injury to nearby organs. Blood clots in the legs or lungs. Heavy bleeding may occur in some patients.
CPT® 58150, Under Hysterectomy Procedures. The Current Procedural Terminology (CPT®) code 58150 as maintained by American Medical Association, is a medical procedural code under the range - Hysterectomy Procedures.
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.
In a total laparoscopic hysterectomy, a surgeon removes your whole uterus (womb) and the opening to the uterus (cervix). Sometimes other reproductive organs are removed, including the fallopian tubes (tubes sending the eggs to the uterus), or ovaries (the egg producers).
Medical Definition of hysterotomy : surgical incision of the uterus usually made by a transabdominal approach also : a procedure (as a cesarean section) involving such an incision.
Laparoscopic-assisted vaginal hysterectomy (LAVH) – 58541-58544, 58548-58554 – The laparoscope is used to detach the structures that are removed vaginally and closed from below.
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, ...
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.
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.
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:
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).
In the article “ Pinpoint Correct Hysterectomy Coding ” (August 2018, pages 16-18), the statement, “… a laparoscopic-assisted vaginal approach — a ‘subset’ of the vaginal approach — in which a scope is inserted via small incisions in the vagina,” is incorrect, and is not the basis for coding a laparoscopically assisted vaginal hysterectomy (LAVH) versus a total laparoscopic hysterectomy (TLH)..
Code selection for a TLH versus a LAVH depends on how the uterine cervix and body are detached from the supporting structures.
Consider the following chart example: The patient was taken to the OR, where her anesthetic was induced. She was then placed in the dorsal lithotomy position and underwent examination under anesthesia. She was then prepped and draped in the usual manner for vaginal and abdominal surgery.
This code specifically excludes hysterectomy codes. If you perform a laparoscopic hysterectomy, BSO, debulking, the proper CPT code would be 58575 (Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed).
For a laparoscopic BSO with staging (for a patient with prior hysterectomy, for instance), you can use 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) with a -22 modifier. That would be billed with the laparoscopic BSO CPT code 58661 with the -59 modifier for a second surgery. With any -22 modifier, you would need to have an operative note and letter requesting increased reimbursement with the rationale, in this case the extra time and effort for “debulking”.
The operative report documentation should clearly describe the procedure and the reason for performing it. You should also append a distinct ICD code, such as C78.5, secondary malignant neoplasm of the large bowel.
The series 58950-58952 can only be used with ICD10 codes for ovarian, tubal or primary peritoneal malignancy. 58953-58954 may be used with any diagnosis. All describe various combinations of procedures commonly performed for advanced gynecologic cancers.
Those procedures are included as “debulking”. 58957 is a code that is used for resection of recurrent gynecologic cancer. If you are doing a primary debulking then you should use 58952-58954 depending on what else is done.
Codes 58953-58956 can be used for cancer at all sites including the uterus. Although the selection of codes for treatment of gyn malignancy is fairly robust, there may be those occasions when the procedure actually performed is varied slightly from the available codes.
For example, a stage 4 ovarian cancer may be coded using 3 codes: C56.1 (malignant neoplasm of the right ovary), C78.6 (secondary malignancy of the peritoneum and retroperitoneum, and J91.0 (malignant pleural effusion). How do you code for borderline ovarian tumors ...