You Be the Coder:
You Can Report 44180 With Unlisted Code 58999
Published on Wed Mar 09, 2011
Question: My ob-gyn documented the following procedure: Excision granulation tissue vaginal cuff. Laparoscopy, extensive (45 minutes) lysis of adhesions of the sigmoid colon to posterior cul-de-sac. Scissors used to dissect lt. Uterosacral stitch out of peritoneum. Inspection revealed connection of the granulation tissue through the vagina into peritoneum. All granulation tissue was removed from vagina as well as inflammation and what appeared to be reaction to stitch. How should I report this?Kentucky SubscriberAnswer: You should report the lysis of adhesions with 44180 (Laparoscopy, surgical, enterolysis [freeing of intestinal adhesion] [separate procedure]) and the removal of the granulation from the vaginal cuff (performed vaginally) as 58999 (Unlisted procedure, female genital system [nonobstetrical]).When reporting an unlisted procedure code, you have to let the payer know how to judge that your charge is reasonable based on the physician work.Better: Check with your surgeon to see what procedure he would like to compare this [...]
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