Good Morning,
I am currently working with a practice in which I had audited and surgery in which they would bill 58571 (Laparocsopy, surgical, with total hysterectomy, for uterus 250 g or less with removal of tube(s) and/or ovary(s)) and 38572 (Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy) single, or multiple with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple). I felt that the appropriate code should have been 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. My feeling was billing with their codes were unbundling. They disagreed because the hysterectomy they said was not radical. I am trying to understand the difference because when I read the op note to me it seemed to cover how I would have billed. This is not my area of expertise for those of you who code this every day I would appreciate any guidance you may offer. The op note is below.
PREOPERATIVE DIAGNOSIS: Endometrial cancer.
POSTOPERATIVE DIAGNOSIS: Endometrial cancer.
OPERATION PERFORMED: Robot assisted total laparoscopic hysterectomy with bilateral salpingo-oophorectomy, pelvic and paraaortic lymphadenectomy.
FINDINGS: The uterus is top normal in size. The ovaries and tubes are grossly normal. There is no gross evidence of adenopathy. There is no peritoneal ascites.
DESCRIPTION OF SURGERY: After the patient was identified and a preoperative time out was observed, the abdomen, vulva, perineum and vagina were prepped and draped in the usual fashion for surgery. A Foley catheter was placed into the bladder and a VCare apparatus was placed into the endometrial cavity with the cup tightly affixed to the cervix. After changing gloves, an incision was made at the left costal margin at the midclavicular line. A 5 mm port was placed into the peritoneal cavity using a 5 camera. CO2 was insufflated into the peritoneal cavity and a 12 mm port was placed in the midline 10 cm above the umbilicus under direct visualization. Accessory 8 mm ports were then placed at 10 cm intervals on either side of the central incision and slightly superior. An additional 8 mm port was placed laterally on the right. The robotic device was then docked.
With monopolar scissors on the #1 port and a bipolar Maryland on the #2 port, the pelvic sidewalls were entered and the ureters were identified. A window was created between the ureter and the infundibulopelvic ligament (IP) and the IP ligament was coagulated with bipolar energy and divided. This was done bilaterally. The round ligaments were then coagulated and divided at the midpoint of the ligament. The broad ligament leaves were then divided and the bladder flap was created. The uterosacral ligaments were then coagulated and divided and the uterine vessels were coagulated and divided on either side. A colpotomy incision was then made over the VCare cup and the uterus, tubes and ovaries were delivered through the vagina.
A radical pelvic lymphadenectomy was then performed bilaterally, removing all lymph bearing tissue in the region defined by the midportion of the common iliac artery, the lateral and medial circumflex iliac veins, the pubic ramus, the obturator nerves and the genitofemoral nerves. The iliac vessels were skeletonized. The specimens were removed transvaginally with the use of
5 mm bags.
The visceral peritoneum overlying the right common iliac artery proximal to the ureter was divided, continuing the dissection over the aorta to a point above the inferior mesenteric artery. The fat pad overlying the inferior vena cava was mobilized from the vessel and the aorta while the ureter was retracted laterally. Perforators were coagulated with bipolar energy. The specimen was labeled appropriately and removed transvaginally in a 5 mm Endobag. With the inferior mesenteric artery retracted anteriorly, the left side of the distal aorta was approached and the psoas muscle on that side was identified with the ureter and gonadal vessels retracted laterally. The lymphatic bundle demarcated by the proximal left common iliac artery, medial margin of the psoas muscle, left margin of the aorta and the inferior mesenteric artery was then mobilized and removed, coagulating margins with bipolar energy. The specimen was labeled appropriately and removed through the vagina in a 5 mm bag.
The vagina was then closed with a running 2-0 Glycomer 90 V-Loc suture. The uterosacral ligament remnants were imbricated with 0 Vicryl. The pelvis was thoroughly lavaged and no evidence of bleeding was noted. All instruments were then removed. Sponge count was correct x3. The robotic device was undocked and CO2 was permitted to exit the abdomen. After the ports were removed, the fascia for the camera port was approximated with 0 Vicryl using an Endoclose device. All skin incisions were closed with 4-0 Vicryl. The patient was then sent to the recovery room in satisfactory condition after the vagina was examined and found to have no injury and no evidence of bleeding. The cuff closure was adequate. All instrument and needle counts were correct.
I am currently working with a practice in which I had audited and surgery in which they would bill 58571 (Laparocsopy, surgical, with total hysterectomy, for uterus 250 g or less with removal of tube(s) and/or ovary(s)) and 38572 (Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy) single, or multiple with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple). I felt that the appropriate code should have been 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. My feeling was billing with their codes were unbundling. They disagreed because the hysterectomy they said was not radical. I am trying to understand the difference because when I read the op note to me it seemed to cover how I would have billed. This is not my area of expertise for those of you who code this every day I would appreciate any guidance you may offer. The op note is below.
PREOPERATIVE DIAGNOSIS: Endometrial cancer.
POSTOPERATIVE DIAGNOSIS: Endometrial cancer.
OPERATION PERFORMED: Robot assisted total laparoscopic hysterectomy with bilateral salpingo-oophorectomy, pelvic and paraaortic lymphadenectomy.
FINDINGS: The uterus is top normal in size. The ovaries and tubes are grossly normal. There is no gross evidence of adenopathy. There is no peritoneal ascites.
DESCRIPTION OF SURGERY: After the patient was identified and a preoperative time out was observed, the abdomen, vulva, perineum and vagina were prepped and draped in the usual fashion for surgery. A Foley catheter was placed into the bladder and a VCare apparatus was placed into the endometrial cavity with the cup tightly affixed to the cervix. After changing gloves, an incision was made at the left costal margin at the midclavicular line. A 5 mm port was placed into the peritoneal cavity using a 5 camera. CO2 was insufflated into the peritoneal cavity and a 12 mm port was placed in the midline 10 cm above the umbilicus under direct visualization. Accessory 8 mm ports were then placed at 10 cm intervals on either side of the central incision and slightly superior. An additional 8 mm port was placed laterally on the right. The robotic device was then docked.
With monopolar scissors on the #1 port and a bipolar Maryland on the #2 port, the pelvic sidewalls were entered and the ureters were identified. A window was created between the ureter and the infundibulopelvic ligament (IP) and the IP ligament was coagulated with bipolar energy and divided. This was done bilaterally. The round ligaments were then coagulated and divided at the midpoint of the ligament. The broad ligament leaves were then divided and the bladder flap was created. The uterosacral ligaments were then coagulated and divided and the uterine vessels were coagulated and divided on either side. A colpotomy incision was then made over the VCare cup and the uterus, tubes and ovaries were delivered through the vagina.
A radical pelvic lymphadenectomy was then performed bilaterally, removing all lymph bearing tissue in the region defined by the midportion of the common iliac artery, the lateral and medial circumflex iliac veins, the pubic ramus, the obturator nerves and the genitofemoral nerves. The iliac vessels were skeletonized. The specimens were removed transvaginally with the use of
5 mm bags.
The visceral peritoneum overlying the right common iliac artery proximal to the ureter was divided, continuing the dissection over the aorta to a point above the inferior mesenteric artery. The fat pad overlying the inferior vena cava was mobilized from the vessel and the aorta while the ureter was retracted laterally. Perforators were coagulated with bipolar energy. The specimen was labeled appropriately and removed transvaginally in a 5 mm Endobag. With the inferior mesenteric artery retracted anteriorly, the left side of the distal aorta was approached and the psoas muscle on that side was identified with the ureter and gonadal vessels retracted laterally. The lymphatic bundle demarcated by the proximal left common iliac artery, medial margin of the psoas muscle, left margin of the aorta and the inferior mesenteric artery was then mobilized and removed, coagulating margins with bipolar energy. The specimen was labeled appropriately and removed through the vagina in a 5 mm bag.
The vagina was then closed with a running 2-0 Glycomer 90 V-Loc suture. The uterosacral ligament remnants were imbricated with 0 Vicryl. The pelvis was thoroughly lavaged and no evidence of bleeding was noted. All instruments were then removed. Sponge count was correct x3. The robotic device was undocked and CO2 was permitted to exit the abdomen. After the ports were removed, the fascia for the camera port was approximated with 0 Vicryl using an Endoclose device. All skin incisions were closed with 4-0 Vicryl. The patient was then sent to the recovery room in satisfactory condition after the vagina was examined and found to have no injury and no evidence of bleeding. The cuff closure was adequate. All instrument and needle counts were correct.
