Wiki LEEP Question

[dmarshall]

Hello OB/GYN Group,

I have searched the archives looking to see if I see anything comparable to this Leep that one of our Physicians did and I am still unsure of correct coding, I am listing a portion of the surgery below:

Procedure Details:
The patient was taken to the Operating Room with IV fluid running and SCDs placed on bilateral lower extremities. Patient was identified as XXX and the procedure verified. A Time Out was held and the above information confirmed.

After induction of general anesthesia, the patient was placed in modified dorsal lithotomy position in Allen type stirrups where she was prepped, draped, and catheterized in the normal, sterile fashion. A cervical block was performed with 1% lidocaine. Lugols solution was placed, limited uptake noted on posterior side. Next the speculum was placed and bovie was set to 70/70. Leep was performed. Superficial specimen marked at 12 o'clock. Deeper specimen collected, marked at 6 oclock. Roller ball used, good hemostasis noted. Monsels applied. Next attention was turned to the abdomen as the patient had a laparascopic tubal done, and I am good with that code. Where I am not sure is when the Op report lists the specimens. Is this enough to indicate endocervical tissue was removed?

Specimens:
ID Type Source Tests Collected by Time Destination
A : cervix stitch at 6 o'clock deep Tissue Cervix TISSUE EXAM XXX, DO 1/19/2024 0819
B : cervix stitch at 12 o'clock superficial Tissue Cervix TISSUE EXAM XXX, DO 1/19/2024 0822
C : bilateral fallopian tubes Tissue Fallopian Tube, Right TISSUE EXAM XXX, DO 1/19/2024 0842

Surgical Path:

Diagnosis
A. Cervix, stitch at 6:00 deep, LEEP excision -
high grade squamous intrepithelial lesion (HSIL / CIN II);
no dysplastic epithelium identified at resection margins.
ICD-10: N87.1
B. Cervix, stitch at 12:00 superior, LEEP excision -
low grade squamous intraepithelial lesion (LSIL / CIN I);
no dysplastic epithelium identified at resection margins.
ICD-10: N87.0
C. Fallopian tubes, bilateral salpingectomy -
complete cross sections of histologically normal fallopian tubes.

I don't usually see Cervix stitch used with a LEEP so I didn't know which direction to go. Would you please advise, I am always happy to receive education regarding Leeps.
Thank you for your assistance.

Dorine Marshall,CPC,COBGC
Tulsa, Ok

 

[csperoni]

It seems to me that you are questioning if the pathology report supports that a LEEP was done because the surgeon used markings via a stitch?
I see no issue with the pathology information supplied supporting cervical tissue. I would definitely feel comfortable coding this as a LEEP based on the op report.
Perhaps your physicians don't often do this, but my docs are using stitch markings all the time (usually vulvar procedures). It is simply done as a way to orient or label the specimen. In your case here, since they did 2 swipes (superficial and deep), the surgeon wanted to make sure the pathologist knew which specimen was which. So superficial got a marking at 12, and deeper and 6.
Please let me know if I am misinterpreting your question.

 

[dmarshall]

It seems to me that you are questioning if the pathology report supports that a LEEP was done because the surgeon used markings via a stitch?
I see no issue with the pathology information supplied supporting cervical tissue. I would definitely feel comfortable coding this as a LEEP based on the op report.
Perhaps your physicians don't often do this, but my docs are using stitch markings all the time (usually vulvar procedures). It is simply done as a way to orient or label the specimen. In your case here, since they did 2 swipes (superficial and deep), the surgeon wanted to make sure the pathologist knew which specimen was which. So superficial got a marking at 12, and deeper and 6.
Please let me know if I am misinterpreting your question.

Morning Christine,
Yes, you are absolutely correct, this is the first time I've noticed the path being reported this way and I wanted to make sure my coding choice of the LEEP was correct for billing the 57522 since no colposcope was used. I usually look for documentation noting that all or part of the endocervix was taken and the wording of both the Op note and path report threw me for a loop. Thank you for your quick response, I feel confident moving forward and using this as a guide for future billing documentation.