Wiki Mini lap and scope Hysto

[juneh]

The bulk of the surgery was done using a scope, the vagina was too small to remove the uterus through it so a decision was made to do a mini lap and the uterus was removed through a small incision in the abdomen. I billed a 58552 and a 58150,52. Any thoughts?

 

[Cmama12]

Hi, you can't bill an open and a laparoscopic code. If a lap procedure is converted to open, you would only bill the open. In this case, it was not a conversion, so if a mini lap was performed simply to remove the speciman, you would not bill anything additional. If the provider documented in such a way to warrant a modifier 22, you could possibly bill 58552-22.

 

[csperoni]

100% agree. The small incision just to remove the specimen does not mean the surgery itself was performed open.
I would also want to check this was a laparoscopic assisted vaginal hysterectomy (LAVH) with tubes and ovaries 58552, and not a total laparoscopic hysterectomy (TLH) with tubes and ovaries 58571. My docs basically never do a LAVH unless they are also doing some type of vaginal repair/procedure. A lot of people misunderstand and believe if the specimen was removed vaginally (or tried to be removed vaginally), it's LAVH and not TLH. It all depends how the surgery itself was accomplished, not how the specimen was removed.
PS - If the uterus was large enough that it was unable to be removed vaginally, I would also check the weight on the pathology to ensure it was not >250gm which would warrant a different code.

 

[juneh]

I am pretty new to OB/GYN, I am using this table, do you see an issue with it?

 

[juneh]

100% agree. The small incision just to remove the specimen does not mean the surgery itself was performed open.
I would also want to check this was a laparoscopic assisted vaginal hysterectomy (LAVH) with tubes and ovaries 58552, and not a total laparoscopic hysterectomy (TLH) with tubes and ovaries 58571. My docs basically never do a LAVH unless they are also doing some type of vaginal repair/procedure. A lot of people misunderstand and believe if the specimen was removed vaginally (or tried to be removed vaginally), it's LAVH and not TLH. It all depends how the surgery itself was accomplished, not how the specimen was removed.
PS - If the uterus was large enough that it was unable to be removed vaginally, I would also check the weight on the pathology to ensure it was not >250gm which would warrant a different code.

Thank you!

 

[csperoni]

I am pretty new to OB/GYN, I am using this table, do you see an issue with it?

That looks correct. In fact, it looks like the ACOG guidance.
I like to discuss LAVH vs TLH when that is a potential concern because many coders see that the uterus and cervix are removed through the vagina and therefore code as LAVH. Just like with your case, it does not matter what opening the specimen is removed from. It matters how the surgeon actually detached the organs, performed the ligation, and closed the vaginal cuff. With the widespread use of daVinci robotic surgery, it is usually TLH, but certainly not always.

 

[Cmama12]

Here's an example of an LAVH - the key is that ligaments are still being cut after they go vaginally.

DESCRIPTION OF THE PROCEDURE:
The patient was taken to the operating room where she was placed under general anesthesia. She was then prepped and draped in the usual sterile fashion in the dorsal lithotomy position. The bladder was drained at the start of the procedure. Sterile speculum inserted without difficulty. A sponge stick was placed due to cervical stenosis.

Attention was then turned to the abdomen where a 1 cm infraumbilical skin incision was made with the scalpel. A Veress needle was used to enter the peritoneal cavity. Entry was confirmed with saline drop test. The abdomen was then insufflated with CO2 gas. A 5 mm trocar was then placed at the umbilical port. Entry into the peritoneal cavity was confirmed with the laparoscope, 2 lower quadrant ports were placed under direct visualization in the left and right lower quadrants after the ligasure was used to take down adhesions in the right lower quadrant to allow port placement. These were both 5 mm ports. The bowel was removed from the cul-de-sac. Uterus, ovaries and tubes were identified. Using the LigaSure cautery device, the infundibulopelvic ligaments were cross-clamped and transected. The round ligaments cross-clamped and transected. The uterine vasculature was serially cross-clamped with the LigaSure device down to the level of the uterine arteries. The camera and laparoscopic instruments were removed.

Attention was then turned to the vaginal canal. A weighted speculum was placed and the cervix was grasped with 2 single-tooth tenaculums. The cervical vaginal junction was injected with diluted Vasopressin. A scalpel was used to circumferentially incise the cervix. The cervical vaginal tissue was dissected with Metzenbaum scissors. The anterior cul-de-sac was entered sharply. A right angle retractor was placed to elevate the bladder. The posterior cul-de-sac was entered sharply with Mayo scissors. A long weighted speculum was placed in the posterior cul-de-sac. A Heaney clamp was then used to clamp the uterosacral ligaments bilaterally, transected with Mayo scissors and suture ligated with 0 Vicryl. The cardinal ligaments were than clamped, cut and suture ligated with 0 Vicryl. The remaining attachments were then serially clamped, cut and suture ligated with 0 Vicryl. The uterus was delivered through the vaginal incision. All pedicles were hemostatic.