Part B Insider (Multispecialty) Coding Alert

Know the clues to determine whether your ob-gyn removed the ovaries.

Youll be able to distinguish a total abdominal hysterectomy from a laparoscopic supracervical hysterectomy thanks to these experts tips on mapping your ob-gyns hysterectomies documentation to these procedures definitions.

The ob-gyn may perform a hysterectomy (removal of the uterus including the corpus and cervix) using an abdominal, vaginal, or laparoscopic approach. Pay attention to these key terms to score 100 on your CPT code selection.

Include Tubes/Ovaries in Abdominal Approach Codes

The ob-gyn may or may not remove the ovaries during an abdominal hysterectomy, but this does not impact the code you select. All CPT codes for the abdominal approach indicate with or without removal of tubes and ovaries, says Melanie Witt, RN,CPC, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M. An abdominal hysterectomy entails the removal of the uterus via a laparotomy.

Example: Your ob-gyn performs a total abdominal hysterectomy including a bilateral pelvic lymph node dissection and omentectomy. You should report 58210 (Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling [biopsy], with or without removal of tube[s], with or without removal of ovary[s]).

Discount Laparoscope for Vaginal Hysterectomies

During a vaginal hysterectomy, the ob-gyn severs and removes all structures via the vaginal canal. The ob-gyn does not use a laparoscope at any time during the procedure.

Example: Your ob-gyn performs a vaginal hysterectomy, and the uterus is under 250 grams. You should report 58260 (Vaginal hysterectomy, for uterus 250 g or less).

Remember, you need to wait for the weight to come back on the path report before submitting the claim, says Amy Mahaffey, biller for an ob-gyn coding practice in Raleigh, N.C.

Create Laparoscopic Groups

While most documentation will clearly identify the abdominal and vaginal approaches, laparoscopic hysterectomies have different -- sometimes confusingly similar -- types. Solve the dilemma by thinking of the laparoscopic hysterectomy codes as subsections:

" total laparoscopic hysterectomy (TLH) (58570-58573, introduced in 2008)

" laparoscopy with vaginal hysterectomy (LAVH) (58550-58554)

" laparoscopic supracervical hysterectomy (LSH) (58541-58544).

Also, dont forget laparoscopic radical hysterectomy with pelvic lymphadenectomy (58548, Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling [biopsy], with removal of tube[s] and ovary[s], if performed).

Key: When choosing between laparoscopic hysterectomy subsets, look at two items. Most of these code sets are subdivided by:

1. the uteruss size as less than or greater than 250 grams

2. with or without removal of tube(s) and/or ovary(s).

Not sure if the ob-gyn removed the ovaries? Look into your documentation for the following terms:

" severed the ovarian ligament -- The answer is no. The ovaries are attached to the uterus and the pelvic sidewall. The ovarian ligament attaches the ovaries to the uterine wall, and the ob-gyn will sever it if hes just removing the uterus.

" severed the infundibulopelvic ligament -- The answer is yes. The infundibulopelvic ligament (also referred to as the IP ligament, or suspensory ligament of the ovary) attaches the ovary to the pelvic cavity, and the ob-gyn will always sever it when hes taking out the ovaries, Witt says.

Go In-Depth With Laparoscopic Procedures

Because accurate coding depends on correctly identifying the hysterectomy the ob-gyn performed, you need to know the distinctions between the different laparoscopic hysterectomy types, Witt says. That means defining what each procedure entails and checking your ob-gyns documentation.

A total laparoscopic hysterectomy (58570-58573) requires the ob-gyn to remove the entire uterine cervix and body of the uterus from the surrounding supporting structures via the laparoscope. The ob-gyn also sutures the vaginal cuff via this approach. The procedure includes bivalving, coring, or morcellating the excised tissues, as required. The ob-gyn then removes the uterus through the vagina or abdomen.

Remember, total laparoscopic hysterectomies have four codes, and the difference between them is the uterus weight (more or less than 250 grams) and whether the ob-gyn removed the tubes/ ovaries, Mahaffery says.

On the other hand, a laparoscopically assisted vaginal hysterectomy (58550-58554) involves laparoscopically detaching the uterine body from the surrounding upper supporting structures only. Then the ob-gyn performs the vaginal portion of the procedure.The ob-gyn enters the vaginal apex and detaches the cervix and uterus from the remaining supporting structures. The ob-gyn then removes the uterus through the vagina.

Again, LAVH codes differ in the weight of the uterus and whether the ob-gyn removed the tubes/ovaries, Mahaffery says.

A laparoscopic supracervical hysterectomy (58541-58544) includes laparoscopically detaching the body of the uterus down to the uterine arteries. The ob-gyn separates the uterine body from the cervix, achieves the hemostasis of the cervical stump, and coagulates the endocervical canal.

The ob-gyn abdominally removes the uterine body by bivalving, coring, or morcellating, as required. Similarly, when youre choosing a code, look for the uteruss weight and whether the ob-gyn removed the tubes/ovaries.

Hint: You may also see terms such as reverse conization with regard to this procedure.

This simply means that the remaining cervix is cored out from above. You should include this technique as part of the procedure, Witt says.

A radical laparoscopic hysterectomy (58548) will start like the vaginally assisted procedure, but the ob-gyn will remove the uterus, parametrium (round, broad, cardinal, and uterosacral ligaments), and the upper onethird to one-half of the vagina. He will take out these structures via the vagina and close the vaginal cuff from the vaginal approach.

If youre confused about what to report, ask the doctor for clarification, Mahaffery says.