Wiki Help! Enterocele repair performed with 58552 laparoscopy, surgical, with vaginal hysterectomy with removal of tubes and/or ovaries

[aTudor28]

Hi everyone. I am auditing a record for a surgeon that performed code 58552 (laparoscopy, surgical, with vaginal hysterectomy with removal of tubes and/or ovaries) and also coded 57270 - repair of enterocele, abdominal approach (separate procedure). There is no mention of an incision being made so I am thinking code 57270 is incorrect. The medical record states:

An enterocele repair was performed with permanent suture using the Halban technique from the abdominal peritoneal aspect. Stitches were run in the sagittal plane to allow closure of the enterocele space. Ureteral integrity and position were not compromised.

I also saw in CPT Assistant, June 2002:
Code 57270 is intended to be reported for repair of enterocele through an abdominal approach with excision of the enterocele sac and reinforcement of support for the repaired peritoneal tissue. Approximation and reinforcement of weakened rectovaginal fascia is included in this procedure. This procedure is sometimes referred to as a Halban’s or Moschcowitz procedure.

Also, per NCCI, “If the code descriptor of a HCPCS/CPT code includes the phrase “separate procedure” the procedure is subject to NCCI PTP edits based on this designation. CMS does not allow separate reporting of a procedure designated as a “separate procedure” when it’s performed at the same patient encounter as another procedure in an anatomically related area through the same skin incision, orifice, or surgical approach.”

Part of me is thinking I have to deny this code (57270) as not being supported. Should the provider add modifier 22 to code 58552 instead? At a loss and would love anyones input. Thanks so much!

 

[Cmama12]

Hi, without seeing the op note, it is unlikely it was an abdominal approach (I have never seen this) with a vaginal hysterectomy. 57268 (sep procedure) is enterocele repair vaginal approach
However, there is a combined code for vaginal hysterectomy with enterocele repair 58270 or 58292. depending on weight.

 

[aTudor28]

Hi, without seeing the op note, it is unlikely it was an abdominal approach (I have never seen this) with a vaginal hysterectomy. 57268 (sep procedure) is enterocele repair vaginal approach
However, there is a combined code for vaginal hysterectomy with enterocele repair 58270 or 58292. depending on weight.

Thanks so much for your response. Here is a copy of the op note.

ANESTHESIA: General Anesthesia
DRAINS: Foley Catheter intra and postoperatively
ESTIMATED BLOOD LOSS: 30cc
SPECIMENS: uterus with tubes (141g)
FINAL COUNTS: Sponge, Lap and Instrument Counts Correct
CONDITION: Patient condition upon transfer to recovery was stable.
PREOPERATIVE DIAGNOSIS: Uterovaginal Prolapse, Vaginal Vault Prolapse, Pelvic Pain, Menorrhagia, Anemia
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURES PERFORMED and DESCRIPTION OF PROCEDURES:
-Laparoscopy with Vaginal Hysterectomy w/salp/ooph 9 58552 N81-2
A uterine manipulator was placed without difficulty. Gloves were changed. A periumbilical incision was made and a five millimeter trocar placed without difficulty. A camera was introduced. Under direct visualization, two five millimetertrocars were introduced and hermostasis was noted. The infundibulopelvic ligaments were transected bilaterally. The transection was carried down through the round ligaments bilaterally. Insufflation was turned off and from the vaginal approach, the cervix was grasped and injected with lidocaine and epinephrine and then cut circumferentially at the cervicovaginal junction. The anterior and posterior cul-de-sacs were entered sharply and retractors were placed into these spaces. The uterosacral and cardinal ligaments were clamped, transected, suture ligated and tagged. The remainder of the broad ligament was transected in a similar manner to the line of laparoscopic cautery. The uterus was removed and submitted for pathologic review- The vaginal cuff was closed in a horizontal manner with figure-of-eight stitches of absorbable suture incorporating the peritoneum. Laparoscopy was performed and the cuff was irrigated and visualized in and out of Trendelenburg positioning. Trocars were removed under direct visualization and sites were closed with subcuticular stitches of absorbable suture. Hemostasis at all incision sites was noted at each layer of closure.

-Colpopexy Ligament Suspension Vaginal Approach
The vaginal apex was noted to be prolapsed. The vaginal apical paracervical endopelvic fascia was approximated in theextraperitoneal pouch of Douglas space to the sacral ligament support and then attached to the posterior vaginal wall with Ethibond suture. The course of the ureters were carefully noted and the ureteral integrity and course was clear.

-Laparoscopy w/ Fulg/Exc Lesions pelv viscera, periton surface 58662 6 K66.0
The pelvis was visualized and fulguration and excision of lesion scarring was performed in the areas of the left pelvic sidewalls and bladder flap. This took over 45 minutes and over half the time of surgery.

-Enterocele Repair 57270 n81.5
An enterocele repair was performed with permanent suture using the Halban technique from the abdominal peritoneal aspect.Stitches were run in the sagittal plane to allow closure of the enterocele space- Ureteral integrity and position were notcompromised.

Cystourethroscopy 52000 prolapse n81.2
The bladder filled. The ureters bilaterally were noted to have vigorous efflux of dye. There was no evidence of ulceration, lesions, diverticula, trabeculations, trauma or suture in the bladder or urethra.

 

[nielynco]

The Halban cul-de-sac closure is a vertical closure of the peritoneum that was first described for abdominal procedures By incorporating these peritoneal sutures vertically, ureteral damage is averted while the surgeon closes off a potential, deep, or obvious enterocele sac. This procedure is also effective for transvaginal surgery because it closes the cul-de-sac without requiring placement of sutures near the ureters. This is what this physician did - the vaginal, not abdominal approach. However, you may not bill both 57282 and 57268 together and no modifier can be used. Just as as aside, the prevention of vault prolapse is an integral part of any vaginal hysterectomy procedure and is described as part of the surgical technique in gyn surgical texts. So you can bill 57268 for the enterocele but should not bill 57282 for the colpopexy. 52000 is bundled into all of these procedures, but you can use a modifier -59 to bypass if you establish a medical indication for doing so. The note does not really say why cystoscopy was necessary. If done to ensure the bladder or ureters were not compromised during the surgery, it would be considered inclusive.