Wiki Laparoscopic IUD removal attempted Hysteroscopic removal of malposition IUD

[Jenetteis]

What codes would I use for Laparoscopic IUD removal, attempted Hysteroscopic removal of malposition IUD, and the surgeon being called into the OR for assistance? Should I use an unlisted code and, if so, would it be 58578 for the uterus or 49329 for the abdomen? For the attempted Hysteroscopy, should I use 58562 with modifier 52 or 53? For the assistant surgeon, Should I use modifier 80? Thank you in advance!

OPERATIVE REPORT
Pre-op Diagnosis: Displacement of the intrauterine contraceptive device, subsequent encounter [T83.32XD]
Post-op Diagnosis: Displacement of the intrauterine contraceptive device, subsequent encounter [T83.32XD]
Procedures
1. Diagnostic hysteroscopy
2. Laparoscopic lysis of adhesions
3. Laparoscopic IUD removal
Surgeons / Assistants
* Dr. C - Primary
* Dr. M - Assisting
No Assistants
Procedure Summary
Anesthesia: General ASA: II
Estimated Blood Loss: 50mL
Drains: [REMOVED] Urethral Catheter Latex 16 Fr (Removed)
Specimens: None
Implants: None

Indications: 35 y.o. female who is having a procedure for Displacement of an intrauterine contraceptive device, subsequent encounter [T83.32XD]. Attempted hysteroscopic removal of IUD on 12/20/22, however, the device was found to be perforated through uterine fundus with intraoperative ultrasound concerning bowel adhesions to arms of IUD. The procedure was aborted at that time and the patient was counseled on the need for LSC IUD removal.

Procedure Details:
After review of informed consent, the patient was taken to the operating room where pre-anesthesia timeout was completed. General anesthesia was then induced without complication.
The patient was then placed in the dorsal lithotomy position in Allen stirrups. The abdomen and perineum were then prepped and draped in the normal sterile fashion. Pre-procedure time out was then completed.
A foley catheter was placed and noted to drain clear yellow urine. Attention was turned to the abdomen. After injection of 0.25% Lidocaine with epinephrine, a 5mm incision was made at the base of the umbilicus with the scalpel. The 5mm Visiport trocar was then used to enter the abdomen under direct laparoscopic visualization. Two 5mm incisions were then made 2cm superior and 2cm medial to the AIS bilaterally. An additional 5mm incision was made approximately 5cm superior to the left lower incision. 5mm trocars were then placed at these sites under direct LSC visualization. Attention was turned to the pelvis. The arms of the IUD were visualized as partially perforated through the right aspect of the fundus of the uterus with myometrium and serosa covering the arms of the IUD. There was also a thin adhesion from the serosa overlying the left arm to the bowel. The Enseal device was used to take down this adhesion. Given the release of this adhesion, the decision was made to attempt HSC removal of the IUD as there was too much tissue overlying the IUD at the fundus to remove it hysteroscopically.
Attention was turned to the pelvis. A speculum was placed in the vagina and the cervix was identified. A tenaculum was placed on the anterior lip of the cervix. The cervix was dilated to accommodate the Myosure scope. The Myosure hysteroscope was introduced into the uterus. The shaft of the IUD was identified. Polyp forceps were placed through the scope and used to grasp the shaft of the IUD. Downward traction was applied to attempt removal of the IUD while watching from above laparoscopically, again, the IUD would not release from the myometrium above.
Attention was again turned to the abdomen and the Enseal device was used to make an incision in the serosa to attempt the release of the IUD from the uterus above. Once the left arm was freed, attention again was turned hysteroscopically to attempt removal. Again, however, the IUD would not release from the myometrium above. At this time Dr. M was called to the OR for assistance with the closure of a uterine incision laparoscopically as it was clear an incision would need to be made in the uterus to remove the IUD.
Attention was again turned laparoscopically. The laparoscopic scissors were then used to make an incision in the uterus at the base of the left arm of the IUD. Traction was applied to the arm and the IUD was completely removed through the top of the uterus. The IUD was removed from the abdomen through one of the left-sided trocars. A V-loc suture was then inserted into the abdomen through one of the left-sided incisions and Dr. M closed the defect in the uterus in a running fashion. Hemostasis was achieved at the operative site. The trocars were removed with no bleeding noted. The abdomen was desufflated and the umbilical trocar was removed. The skin incisions were closed with 4-0 Monocryl and Dermabond. The tenaculum was removed from the cervix. Bleeding from the tenaculum sites was noted and hemostasis was achieved with silver nitrate sticks and pressure. The patient tolerated the procedure well with no complications.
Findings: Arms of the IUD were visualized as partially perforated through the right aspect of the fundus of the uterus with myometrium and serosa covering the arms of the IUD.
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Attestation: I performed the procedure.

 

[nielynco]

What codes would I use for Laparoscopic IUD removal, attempted Hysteroscopic removal of malposition IUD, and the surgeon being called into the OR for assistance? Should I use an unlisted code and, if so, would it be 58578 for the uterus or 49329 for the abdomen? For the attempted Hysteroscopy, should I use 58562 with modifier 52 or 53? For the assistant surgeon, Should I use modifier 80? Thank you in advance!

OPERATIVE REPORT
Pre-op Diagnosis: Displacement of the intrauterine contraceptive device, subsequent encounter [T83.32XD]
Post-op Diagnosis: Displacement of the intrauterine contraceptive device, subsequent encounter [T83.32XD]
Procedures
1. Diagnostic hysteroscopy
2. Laparoscopic lysis of adhesions
3. Laparoscopic IUD removal
Surgeons / Assistants
* Dr. C - Primary
* Dr. M - Assisting
No Assistants
Procedure Summary
Anesthesia: General ASA: II
Estimated Blood Loss: 50mL
Drains: [REMOVED] Urethral Catheter Latex 16 Fr (Removed)
Specimens: None
Implants: None

Indications: 35 y.o. female who is having a procedure for Displacement of an intrauterine contraceptive device, subsequent encounter [T83.32XD]. Attempted hysteroscopic removal of IUD on 12/20/22, however, the device was found to be perforated through uterine fundus with intraoperative ultrasound concerning bowel adhesions to arms of IUD. The procedure was aborted at that time and the patient was counseled on the need for LSC IUD removal.

Procedure Details:
After review of informed consent, the patient was taken to the operating room where pre-anesthesia timeout was completed. General anesthesia was then induced without complication.
The patient was then placed in the dorsal lithotomy position in Allen stirrups. The abdomen and perineum were then prepped and draped in the normal sterile fashion. Pre-procedure time out was then completed.
A foley catheter was placed and noted to drain clear yellow urine. Attention was turned to the abdomen. After injection of 0.25% Lidocaine with epinephrine, a 5mm incision was made at the base of the umbilicus with the scalpel. The 5mm Visiport trocar was then used to enter the abdomen under direct laparoscopic visualization. Two 5mm incisions were then made 2cm superior and 2cm medial to the AIS bilaterally. An additional 5mm incision was made approximately 5cm superior to the left lower incision. 5mm trocars were then placed at these sites under direct LSC visualization. Attention was turned to the pelvis. The arms of the IUD were visualized as partially perforated through the right aspect of the fundus of the uterus with myometrium and serosa covering the arms of the IUD. There was also a thin adhesion from the serosa overlying the left arm to the bowel. The Enseal device was used to take down this adhesion. Given the release of this adhesion, the decision was made to attempt HSC removal of the IUD as there was too much tissue overlying the IUD at the fundus to remove it hysteroscopically.
Attention was turned to the pelvis. A speculum was placed in the vagina and the cervix was identified. A tenaculum was placed on the anterior lip of the cervix. The cervix was dilated to accommodate the Myosure scope. The Myosure hysteroscope was introduced into the uterus. The shaft of the IUD was identified. Polyp forceps were placed through the scope and used to grasp the shaft of the IUD. Downward traction was applied to attempt removal of the IUD while watching from above laparoscopically, again, the IUD would not release from the myometrium above.
Attention was again turned to the abdomen and the Enseal device was used to make an incision in the serosa to attempt the release of the IUD from the uterus above. Once the left arm was freed, attention again was turned hysteroscopically to attempt removal. Again, however, the IUD would not release from the myometrium above. At this time Dr. M was called to the OR for assistance with the closure of a uterine incision laparoscopically as it was clear an incision would need to be made in the uterus to remove the IUD.
Attention was again turned laparoscopically. The laparoscopic scissors were then used to make an incision in the uterus at the base of the left arm of the IUD. Traction was applied to the arm and the IUD was completely removed through the top of the uterus. The IUD was removed from the abdomen through one of the left-sided trocars. A V-loc suture was then inserted into the abdomen through one of the left-sided incisions and Dr. M closed the defect in the uterus in a running fashion. Hemostasis was achieved at the operative site. The trocars were removed with no bleeding noted. The abdomen was desufflated and the umbilical trocar was removed. The skin incisions were closed with 4-0 Monocryl and Dermabond. The tenaculum was removed from the cervix. Bleeding from the tenaculum sites was noted and hemostasis was achieved with silver nitrate sticks and pressure. The patient tolerated the procedure well with no complications.
Findings: Arms of the IUD were visualized as partially perforated through the right aspect of the fundus of the uterus with myometrium and serosa covering the arms of the IUD.
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Attestation: I performed the procedure.

First, I hope you noticed the dictation error

Given the release of this adhesion, the decision was made to attempt HSC removal of the IUD as there was too much tissue overlying the IUD at the fundus to remove it hysteroscopically. He meant there was too much tissue overlying the IUD at the fundus to remove it laparoscopically.

That said, I would probably go for the unlisted 58578 since they made an incision into the uterus to remove the IUD. I would compare that work to 49402, removal of peritoneal foreign body or 58520 (Hysterorrhaphy) as the work RVUs assigned to these codes would seem to be equivalent to the work described. The purpose of the modifier -53 was to reimburse for a procedure that was completely stopped and the patient goes to recovery. I would suggest using a modifier -52 in this case as some of the work was performed. Dr. M apparently only assisted for the suturing of the uterus and may not have been present for the entire procedure so that would be a modifier -81. You should check with the provider to see if he/she agrees with this assessment before billing. I would not use 49329 even though they removed a thin adhesion as the IUD was not in the peritoneal cavity or removed from that position. Hopefully this will be a once in a lifetime surgery for this provider.

 

[Jenetteis]

First, I hope you noticed the dictation error

That said, I would probably go for the unlisted 58578 since they made an incision into the uterus to remove the IUD. I would compare that work to 49402, removal of peritoneal foreign body or 58520 (Hysterorrhaphy) as the work RVUs assigned to these codes would seem to be equivalent to the work described. The purpose of the modifier -53 was to reimburse for a procedure that was completely stopped and the patient goes to recovery. I would suggest using a modifier -52 in this case as some of the work was performed. Dr. M apparently only assisted for the suturing of the uterus and may not have been present for the entire procedure so that would be a modifier -81. You should check with the provider to see if he/she agrees with this assessment before billing. I would not use 49329 even though they removed a thin adhesion as the IUD was not in the peritoneal cavity or removed from that position. Hopefully this will be a once in a lifetime surgery for this provider.

Nielynco, I wanted to make sure I understand correctly, for Dr. C, I would bill 58578, 52 (compare the work to 49402), and for Dr. M, I would bill 58578, 81 (compare the work to 58520). I've never billed an unlisted code before, do you have a letter you've used for the Unlisted CPT? Thank you

 

[Cmama12]

Nielynco, I wanted to make sure I understand correctly, for Dr. C, I would bill 58578, 52 (compare the work to 49402), and for Dr. M, I would bill 58578, 81 (compare the work to 58520). I've never billed an unlisted code before, do you have a letter you've used for the Unlisted CPT? Thank you

Here's an example letter:
Date: (Today’s Date)

Medical Director:

RE: (patient’s name)

Date of Service:

According to the CPT instruction change for unlisted codes, we cannot “select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code.”
I have found that no CPT code exists for (type description of procedure performed).
Therefore, I am submitting (type unlisted CPT code and description of code) for my services provided to your insured.
The charge for code (type unlisted CPT code) is $ (type charge for procedure).
I am basing the fee for this service on CPT code (type comparable CPT code chosen), which has a work RVU of (enter RVUs).
I am attaching a detailed copy of my operative report.

Sincerely,


(Type Clinician’s Name with initials)

(Type Coding Contact Name with initials, if applicable)

(Type Phone number with area code)