Wiki Coding a TAH with extensive loa

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nwilliams714

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How would I code a total abdominal hysterectomy with extensive peritoneal adhesions? The op report states that adhesions had to be removed before the uterus could be removed, but does not state length of time it took to remove adhesions. The report also does not state how dense the adhesions were, just their locations. Since the adhesions were done abdominally with the hysterectomy I am not sure what loa code to use.
 
No documentation = no code

If there is no documentation specifying the extent of the LoA then you can't code it separately. It's considered an integral part of the hysterectomy.

IF you had documentation of the length of time or difficulty of the LoA you could add a -22 mod to your primary procedure.

Sorry.

F Tessa Bartels, CPC, CEMC
 
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