OBcoder2017
Guest
My understanding (through ACOG) of a Laparoscopic Assist Vaginal Hysterectomy w BSO (58552) is that the beginning of the procedure, which includes significant ligation and excision, is performed through the Laparoscope and then the remainder of the procedure is completed vaginally. I have queried my doctor on his approach and he advised me that he only uses the Laparoscope diagnostically to determine what is causing pain, problems, etc and then if it is determined that he can do the procedure vaginally, he does the entire vaginal hysterectomy through the vaginal approach, and then revisualizes the area through the laparoscope to check for bleeding or other problems before removing the scope. I code this with a Diagnostic Laparoscopy (49320) with a 59 modifier when appropriate and a vaginal hysterectomy w BSO (58262). The hospital, however, codes this as a Laparoscopic Assist Vaginal Hysterectomy (58552) even though I have advised them that that is not what my doctor performs. Therefore, I am submitting a different code to the insurance company than they are. I believe that are coding what they think is correct and I am coding what I think is correct. I am sure this is causing a problem with the insurance companies. I want my AAPC colleagues to weigh in on this and make sure I am coding it correctly. I have included the Op note for your review. Thank you for your time!
PREOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Abnormal uterine bleeding.
3. History of endometriosis.
4. Second-degree uterine prolapse.
POSTOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Abnormal uterine bleeding.
3. History of endometriosis.
4. Second-degree uterine prolapse.
OPERATIONS:
1. Diagnostic laparoscopy.
2. Total vaginal hysterectomy.
3. Bilateral salpingo-oophorectomy.
SURGEON:
ASSISTANT:
ANESTHESIA: General with endotracheal intubation.
ESTIMATED BLOOD LOSS: 250 mL.
COMPLICATIONS: None.
HISTORY: This patient is a 42-year-old female. She is gravida 2, para
2-0-0-2. This patient is having problems with heavy painful menses. She also
is having some pelvic pain at all times and she is having severe
dyspareunia. On examination, she does have a second-degree uterine prolapse
with the cervix coming down to the vaginal opening and she has diffuse
tenderness. She does have a past history of some endometriosis. We have
discussed all the medical and surgical options. She does desire proceeding
with hysterectomy. The plan is to carry out the surgery vaginal if at all
possible. If they cannot be done vaginal, then we would do total abdominal
hysterectomy and bilateral salpingo-oophorectomy. The patient does desire
that her ovaries be removed. The operative procedures have been discussed
with the patient and also the risk including the risk of anesthesia,
bleeding, infection, and injury to other organs and also adhesion formation
following surgery. The patient understood all this. She did want to proceed
with the surgery as discussed with her.
DESCRIPTION OF PROCEDURE: With the patient in supine position, general
anesthesia was carried out with endotracheal intubation. The patient was
placed in Allen stirrups and in dorsal lithotomy position and prepped and
draped in the usual manner. Speculum placed in the vagina. Anterior lip of
the cervix grasped with a single-tooth tenaculum. With gentle traction, the
cervix comes down to the vaginal opening consistent with at least
second-degree uterine prolapse. The Valtchev apparatus was then attached to
the tenaculum. Incision was made in the inferior aspect of the umbilicus.
Veress needle placed without difficulty, 2.5 liters of CO2 insufflated.
Then, the laparoscope was placed without difficulty and a second probe
placed 2 cm above the pubic bone. On visual inspection of the pelvic area,
the patient has no pelvic adhesions. There was some endometriosis on the
left uterosacral ligament and some on the back of the cervix. However, with
these findings, it was felt hysterectomy can be carried out vaginal and
attention was turned back to the vagina where weighted speculum was again
placed. The Valtchev apparatus removed. A circumferential incision made
around the posterior aspect of the cervix and the posterior peritoneal space
entered without difficulty, retractor placed in this space. Then, the
incision was extended anteriorly around the cervix and the bladder pushed
off the cervix anteriorly. Then, the uterosacral and cardinal ligaments on
each side were clamped, cut, and suture ligated using 0 Vicryl suture. Then,
the anterior peritoneal space was easily identified and opened and retractor
placed in this space. Then, the remainder of the ligamentous structures on
each side of the uterus were clamped, cut, and suture ligated using 0 Vicryl
suture until the cervix and uterus had been completely removed. The cervix
and uterus were passed off the table as a specimen. Then, the right ovary
was grasped with a Babcock clamp, brought into the operative field. The
infundibulopelvic ligament clamped and the ovary and tube excised. The
pedicle suture ligated using 0 Vicryl suture. Then, the left tube and ovary
were grasped with a Babcock clamp, brought into the operative field. The
infundibulopelvic ligament clamped and the ovary and tube excised. The
pedicle suture ligated using 0 Vicryl suture. There is no bleeding from any
of the pedicles and the pelvic peritoneum was then closed with a pursestring
stitch of 0 Vicryl suture and the vaginal cuff closed. There is no bleeding
from the vaginal cuff at the end of the closure, there was good vaginal
depth and no cystocele. Her rectocele of significance identified. At this
time, revisualization through the laparoscope reveals no active bleeding at
all from the pelvic area and there is essentially no blood in the
cul-de-sac. At this time, the CO2 was allowed to expel from the abdomen. The
instruments were removed from the abdomen. Each incision closed with 1
subcuticular stitch of 4-0 chromic suture.
The sponge and instrument counts were correct on all occasions. The patient
tolerated the procedure well. There were no complications and the patient
was awake and vitals stable prior to leaving the operating room.
PREOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Abnormal uterine bleeding.
3. History of endometriosis.
4. Second-degree uterine prolapse.
POSTOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Abnormal uterine bleeding.
3. History of endometriosis.
4. Second-degree uterine prolapse.
OPERATIONS:
1. Diagnostic laparoscopy.
2. Total vaginal hysterectomy.
3. Bilateral salpingo-oophorectomy.
SURGEON:
ASSISTANT:
ANESTHESIA: General with endotracheal intubation.
ESTIMATED BLOOD LOSS: 250 mL.
COMPLICATIONS: None.
HISTORY: This patient is a 42-year-old female. She is gravida 2, para
2-0-0-2. This patient is having problems with heavy painful menses. She also
is having some pelvic pain at all times and she is having severe
dyspareunia. On examination, she does have a second-degree uterine prolapse
with the cervix coming down to the vaginal opening and she has diffuse
tenderness. She does have a past history of some endometriosis. We have
discussed all the medical and surgical options. She does desire proceeding
with hysterectomy. The plan is to carry out the surgery vaginal if at all
possible. If they cannot be done vaginal, then we would do total abdominal
hysterectomy and bilateral salpingo-oophorectomy. The patient does desire
that her ovaries be removed. The operative procedures have been discussed
with the patient and also the risk including the risk of anesthesia,
bleeding, infection, and injury to other organs and also adhesion formation
following surgery. The patient understood all this. She did want to proceed
with the surgery as discussed with her.
DESCRIPTION OF PROCEDURE: With the patient in supine position, general
anesthesia was carried out with endotracheal intubation. The patient was
placed in Allen stirrups and in dorsal lithotomy position and prepped and
draped in the usual manner. Speculum placed in the vagina. Anterior lip of
the cervix grasped with a single-tooth tenaculum. With gentle traction, the
cervix comes down to the vaginal opening consistent with at least
second-degree uterine prolapse. The Valtchev apparatus was then attached to
the tenaculum. Incision was made in the inferior aspect of the umbilicus.
Veress needle placed without difficulty, 2.5 liters of CO2 insufflated.
Then, the laparoscope was placed without difficulty and a second probe
placed 2 cm above the pubic bone. On visual inspection of the pelvic area,
the patient has no pelvic adhesions. There was some endometriosis on the
left uterosacral ligament and some on the back of the cervix. However, with
these findings, it was felt hysterectomy can be carried out vaginal and
attention was turned back to the vagina where weighted speculum was again
placed. The Valtchev apparatus removed. A circumferential incision made
around the posterior aspect of the cervix and the posterior peritoneal space
entered without difficulty, retractor placed in this space. Then, the
incision was extended anteriorly around the cervix and the bladder pushed
off the cervix anteriorly. Then, the uterosacral and cardinal ligaments on
each side were clamped, cut, and suture ligated using 0 Vicryl suture. Then,
the anterior peritoneal space was easily identified and opened and retractor
placed in this space. Then, the remainder of the ligamentous structures on
each side of the uterus were clamped, cut, and suture ligated using 0 Vicryl
suture until the cervix and uterus had been completely removed. The cervix
and uterus were passed off the table as a specimen. Then, the right ovary
was grasped with a Babcock clamp, brought into the operative field. The
infundibulopelvic ligament clamped and the ovary and tube excised. The
pedicle suture ligated using 0 Vicryl suture. Then, the left tube and ovary
were grasped with a Babcock clamp, brought into the operative field. The
infundibulopelvic ligament clamped and the ovary and tube excised. The
pedicle suture ligated using 0 Vicryl suture. There is no bleeding from any
of the pedicles and the pelvic peritoneum was then closed with a pursestring
stitch of 0 Vicryl suture and the vaginal cuff closed. There is no bleeding
from the vaginal cuff at the end of the closure, there was good vaginal
depth and no cystocele. Her rectocele of significance identified. At this
time, revisualization through the laparoscope reveals no active bleeding at
all from the pelvic area and there is essentially no blood in the
cul-de-sac. At this time, the CO2 was allowed to expel from the abdomen. The
instruments were removed from the abdomen. Each incision closed with 1
subcuticular stitch of 4-0 chromic suture.
The sponge and instrument counts were correct on all occasions. The patient
tolerated the procedure well. There were no complications and the patient
was awake and vitals stable prior to leaving the operating room.