Leiomyoma removal without uterus present


Columbus, GA
Best answers
I have a case where our physician thought he was going in for a laparoscopic left salpingo-oophorectomy for a large ovarian neoplasm of uncertain behavior. However, after getting the pathology back it states that "no ovarian parenchyma or fallopian tube identified." The pathologists call it a "Leiomyoma (s) with hyaline degeneration and dystrophic calcifications."

I queried the physician and he laid it back in my court to try to figure out the best coding scenario for this procedure. He said that was my expertise! :D

He went into the surgery having the patient being referred to him by a PCP. She was a poor historian and she couldn't remember if she had any ovaries after she had her hysterectomy.

The physician states that the "12 cm tumor was solid and calcified and it appeared to originate from the left side of the pelvis, but occupied the entire pelvic cavity."

I looked at 58546 (total weight was 410 grams), but he didn't remove the leiomyoma from the uterus. 58662 does talk about fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method," but I would hardly call a 410 gram leiomyoma a lesion.

And do I use D25.9 for Leiomyoma, unspecified, or do I use N80.3 Endometriosis of pelvic peritoneum or do I use both?

I'm at a loss.