Ob-Gyn Coding Alert

Question: My ob-gyn performed a total abdominal hysterectomy (TAH) with excision of retroperitoneal mass and excision of bladder mass, lysis of adhesions, and cystotomy repair. Should I count the excision of the retroperitoneal and bladder masses as bundled with TAH?

Montana Subscriber

Answer: No, you should not count them as bundled with the TAH (58150, Total abdominal hysterectomy [corpus and cervix],with or without removal of tube[s], with or without removal of ovary[s]) -- unless your ob-gyn documents these circumstances:

• these masses were somehow attached to the uterus or part of the connections that the ob-gyn removed along with the  uterus, or
• it was part of radical debulking for cancer (for which you would use a different code than 58150).

If not part of debulking, you should be looking at 49203-49205 (Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors ...).