Wiki TLH with mini-Laparotomy incision

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scurtis7189

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The physician started a hysterectomy with a laparoscopic approach. The uterus was over 500 grams and a mini-laparotomy incision was made to remove the specimen. The laparotomy incision was then closed and the procedure was finished as a laparoscopic hysterectomy.

What CPT code should be used in this situation?

Thank you.
 
scurtis7189 said:
The physician started a hysterectomy with a laparoscopic approach. The uterus was over 500 grams and a mini-laparotomy incision was made to remove the specimen. The laparotomy incision was then closed and the procedure was finished as a laparoscopic hysterectomy.

What CPT code should be used in this situation?

Thank you.
Click to expand...
Hey did you ever figure this one out? I know it was from so long ago. I've just come across this for my practice
 
When a procedure is PERFORMED laparoscopically, it should be coded that way. An enlarged incision only to remove the specimen, without doing any part of the actual surgery through the open incision is not a conversion to open. Depending on documentation, it is possible -22 is warranted on 5857X.
If the procedure begins laparoscopically, and the physician must open the patient and PERFORM the surgery or remaining surgery via the open abdomen, it is then coded as open. Also adding the diagnosis for laparoscope converted to open. Again, depending on documentation, it is possible -22 is warranted on the open hysterectomy code.
Here were some other threads discussing:
And some other web references:
 
csperoni said:
When a procedure is PERFORMED laparoscopically, it should be coded that way. An enlarged incision only to remove the specimen, without doing any part of the actual surgery through the open incision is not a conversion to open. Depending on documentation, it is possible -22 is warranted on 5857X.
If the procedure begins laparoscopically, and the physician must open the patient and PERFORM the surgery or remaining surgery via the open abdomen, it is then coded as open. Also adding the diagnosis for laparoscope converted to open. Again, depending on documentation, it is possible -22 is warranted on the open hysterectomy code.
Here were some other threads discussing:
And some other web references:
Click to expand...
Thank you so much!!!
 
Hello to All,
After reading the article in AAPC magazine June 2024 " Weigh In on Hysterectomy Coding" page 36, I recalled this conversation on Mini laparotomy for removing a large organ/specimen Only. I would like to bring to your attention that there is a possible error in coding OBGYN case where the surgeon did the intended LTH but because the the 'uterus was too large to remove vaginally" MD did a mini laparotomy. The author telling us to code it as Open surgery 58150. Could you please confirm that 58150 open is incorrect code and if yes, who should we contact to? If I am wrong, then I apologize. Thank you to all of you.

"Case example: A patient with menorrhagia and an enlarged uterus (874 grams) presented for a robotic assisted total laparoscopic hysterectomy with bilateral salpingectomy. After the uterus, cervix, and bilateral fallopian tubes were amputated with electrocautery, an endo catch bag was placed through the vagina. However, the uterus was too large to remove vaginally so the decision was made to proceed with a mini laparotomy. A separate Pfannenstiel incision was made and carried down to the underlying fascia. The uterus and endo catch bag were then brought to the incision and delivered through the mini laparotomy.

For this case example, you would be correct to assign CPT® 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s), for the hysterectomy requiring a separate incision to remove the specimen. The laparoscopic procedure was converted to an open procedure; therefore, a code for the open procedure is reported. This guidance is provided within the NCCI Policy Manual, Chapter 1.


https://aapcpublishing.s3.amazonaws.com/AAPCtheMagazine/June2024/index.html?_gl=1*oe3u4j*_ga*MTQzODM3NTAwMy4xNjQ5MDk3NzI4*_ga_YCM4N7Z8H4*MTcxNjg0MDI2NS4xMzMuMS4xNzE2ODQwODk5LjM0LjAuMA
 
natashalage said:
Hello to All,
After reading the article in AAPC magazine June 2024 " Weigh In on Hysterectomy Coding" page 36, I recalled this conversation on Mini laparotomy for removing a large organ/specimen Only. I would like to bring to your attention that there is a possible error in coding OBGYN case where the surgeon did the intended LTH but because the the 'uterus was too large to remove vaginally" MD did a mini laparotomy. The author telling us to code it as Open surgery 58150. Could you please confirm that 58150 open is incorrect code and if yes, who should we contact to? If I am wrong, then I apologize. Thank you to all of you.

"Case example: A patient with menorrhagia and an enlarged uterus (874 grams) presented for a robotic assisted total laparoscopic hysterectomy with bilateral salpingectomy. After the uterus, cervix, and bilateral fallopian tubes were amputated with electrocautery, an endo catch bag was placed through the vagina. However, the uterus was too large to remove vaginally so the decision was made to proceed with a mini laparotomy. A separate Pfannenstiel incision was made and carried down to the underlying fascia. The uterus and endo catch bag were then brought to the incision and delivered through the mini laparotomy.

For this case example, you would be correct to assign CPT® 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s), for the hysterectomy requiring a separate incision to remove the specimen. The laparoscopic procedure was converted to an open procedure; therefore, a code for the open procedure is reported. This guidance is provided within the NCCI Policy Manual, Chapter 1.


https://aapcpublishing.s3.amazonaws.com/AAPCtheMagazine/June2024/index.html?_gl=1*oe3u4j*_ga*MTQzODM3NTAwMy4xNjQ5MDk3NzI4*_ga_YCM4N7Z8H4*MTcxNjg0MDI2NS4xMzMuMS4xNzE2ODQwODk5LjM0LjAuMA
Click to expand...
I did not read the magazine and just looked at that article now. I (like @Cmama12 ) disagree with the author on that example given. I do agree that if a laparoscopic procedure is converted to open that you code the open procedure. I do NOT agree that an incision only to remove a large specimen is a conversion to open. Writing an email right now!!
 
csperoni said:
I did not read the magazine and just looked at that article now. I (like @Cmama12 ) disagree with the author on that example given. I do agree that if a laparoscopic procedure is converted to open that you code the open procedure. I do NOT agree that an incision only to remove a large specimen is a conversion to open. Writing an email right now!!
Click to expand...
I don't have access to this article and don't know who wrote it, but you are correct if this was what they said, it is incorrect information. I will contact my AAPC contact offline and report on this.
 
natashalage said:
Hello to All,
After reading the article in AAPC magazine June 2024 " Weigh In on Hysterectomy Coding" page 36, I recalled this conversation on Mini laparotomy for removing a large organ/specimen Only. I would like to bring to your attention that there is a possible error in coding OBGYN case where the surgeon did the intended LTH but because the the 'uterus was too large to remove vaginally" MD did a mini laparotomy. The author telling us to code it as Open surgery 58150. Could you please confirm that 58150 open is incorrect code and if yes, who should we contact to? If I am wrong, then I apologize. Thank you to all of you.

"Case example: A patient with menorrhagia and an enlarged uterus (874 grams) presented for a robotic assisted total laparoscopic hysterectomy with bilateral salpingectomy. After the uterus, cervix, and bilateral fallopian tubes were amputated with electrocautery, an endo catch bag was placed through the vagina. However, the uterus was too large to remove vaginally so the decision was made to proceed with a mini laparotomy. A separate Pfannenstiel incision was made and carried down to the underlying fascia. The uterus and endo catch bag were then brought to the incision and delivered through the mini laparotomy.

For this case example, you would be correct to assign CPT® 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s), for the hysterectomy requiring a separate incision to remove the specimen. The laparoscopic procedure was converted to an open procedure; therefore, a code for the open procedure is reported. This guidance is provided within the NCCI Policy Manual, Chapter 1.


https://aapcpublishing.s3.amazonaws.com/AAPCtheMagazine/June2024/index.html?_gl=1*oe3u4j*_ga*MTQzODM3NTAwMy4xNjQ5MDk3NzI4*_ga_YCM4N7Z8H4*MTcxNjg0MDI2NS4xMzMuMS4xNzE2ODQwODk5LjM0LjAuMA
Click to expand...
I have in fact commented to AAPC staff regarding this coding advice. The greater than 250 mg vaginal hysterectomy codes include additional work required to get the larger uterus out. In the past this was done via morcellation which has come into disrepute due to possible issue if the uterus was not benign and now many surgeons are switching to taking it out via a mini laparotomy - this work is already accounted for in the vaginal hysterectomy codes for greater than 250 mg and so the coding should not change just because the uterus is not cut up into small pieces so it can be extracted vaginally. I remember having this conversation with a member of ACOG's coding committee a few years ago and that was his opinion also.
 
natashalage said:
Hello to All,
After reading the article in AAPC magazine June 2024 " Weigh In on Hysterectomy Coding" page 36, I recalled this conversation on Mini laparotomy for removing a large organ/specimen Only. I would like to bring to your attention that there is a possible error in coding OBGYN case where the surgeon did the intended LTH but because the the 'uterus was too large to remove vaginally" MD did a mini laparotomy. The author telling us to code it as Open surgery 58150. Could you please confirm that 58150 open is incorrect code and if yes, who should we contact to? If I am wrong, then I apologize. Thank you to all of you.

"Case example: A patient with menorrhagia and an enlarged uterus (874 grams) presented for a robotic assisted total laparoscopic hysterectomy with bilateral salpingectomy. After the uterus, cervix, and bilateral fallopian tubes were amputated with electrocautery, an endo catch bag was placed through the vagina. However, the uterus was too large to remove vaginally so the decision was made to proceed with a mini laparotomy. A separate Pfannenstiel incision was made and carried down to the underlying fascia. The uterus and endo catch bag were then brought to the incision and delivered through the mini laparotomy.

For this case example, you would be correct to assign CPT® 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s), for the hysterectomy requiring a separate incision to remove the specimen. The laparoscopic procedure was converted to an open procedure; therefore, a code for the open procedure is reported. This guidance is provided within the NCCI Policy Manual, Chapter 1.


https://aapcpublishing.s3.amazonaws.com/AAPCtheMagazine/June2024/index.html?_gl=1*oe3u4j*_ga*MTQzODM3NTAwMy4xNjQ5MDk3NzI4*_ga_YCM4N7Z8H4*MTcxNjg0MDI2NS4xMzMuMS4xNzE2ODQwODk5LjM0LjAuMA
Click to expand...
I did receive a response from AAPC regarding the advice in this article. They specifically referenced AHA Coding Clinic for HCPCS, 4th quarter 2019.
AHA Coding Clinic advised if a port incision is enlarged to remove a larger specimen, that is coded as laparoscopic, but if a separate incision is made, it is then considered converted to open and coded as open. I certainly agree with the first portion, that enlarging a port/trocar incision is coded as laparoscopic. However, it is MY OPINION if a separate incision is made ONLY to remove the specimen (NO surgery done through the open incision), I would still consider that a laparoscopic surgery. If there was any surgery done through that open incision, I would then consider that conversion to open and code as open.
That being said, I cannot recall seeing a case where the surgeon made a separate incision. I looked over about a year of cases for 4 surgeons where several times a port/trocar incision was enlarged, but did not find a single occurrence of a separate incision.
I now understand why the article gives the advice they do, even if I'm still not convinced. I would also add without the separate incision specification, it is very easy to misinterpret that any mini-laparotomy is coded as open, which is definitely not the AHA Coding Clinic advice.
 
csperoni said:
I did receive a response from AAPC regarding the advice in this article. They specifically referenced AHA Coding Clinic for HCPCS, 4th quarter 2019.
AHA Coding Clinic advised if a port incision is enlarged to remove a larger specimen, that is coded as laparoscopic, but if a separate incision is made, it is then considered converted to open and coded as open. I certainly agree with the first portion, that enlarging a port/trocar incision is coded as laparoscopic. However, it is MY OPINION if a separate incision is made ONLY to remove the specimen (NO surgery done through the open incision), I would still consider that a laparoscopic surgery. If there was any surgery done through that open incision, I would then consider that conversion to open and code as open.
That being said, I cannot recall seeing a case where the surgeon made a separate incision. I looked over about a year of cases for 4 surgeons where several times a port/trocar incision was enlarged, but did not find a single occurrence of a separate incision.
I now understand why the article gives the advice they do, even if I'm still not convinced. I would also add without the separate incision specification, it is very easy to misinterpret that any mini-laparotomy is coded as open, which is definitely not the AHA Coding Clinic advice.
Click to expand...
thanks so much!
 
csperoni said:
I did receive a response from AAPC regarding the advice in this article. They specifically referenced AHA Coding Clinic for HCPCS, 4th quarter 2019.
AHA Coding Clinic advised if a port incision is enlarged to remove a larger specimen, that is coded as laparoscopic, but if a separate incision is made, it is then considered converted to open and coded as open. I certainly agree with the first portion, that enlarging a port/trocar incision is coded as laparoscopic. However, it is MY OPINION if a separate incision is made ONLY to remove the specimen (NO surgery done through the open incision), I would still consider that a laparoscopic surgery. If there was any surgery done through that open incision, I would then consider that conversion to open and code as open.
That being said, I cannot recall seeing a case where the surgeon made a separate incision. I looked over about a year of cases for 4 surgeons where several times a port/trocar incision was enlarged, but did not find a single occurrence of a separate incision.
I now understand why the article gives the advice they do, even if I'm still not convinced. I would also add without the separate incision specification, it is very easy to misinterpret that any mini-laparotomy is coded as open, which is definitely not the AHA Coding Clinic advice.
Click to expand...
And I agree with your take. And you will also notice that if you followed that advice (reporting 58150) the surgeon will get paid LESS for doing more work.
 
I want to make sure I am coding my providers surgery correctly; it was Robotic assisted Total Laparoscopic Hysterectomy with bilateral Salpingectomy with mini-laparotomy. Per the path report the weight is 309 grams.
Everything detached laparoscopically. Mini-laparotomy performed to remove the specimens. Based on all the above information do I have to code this as 58150 because he made a small incision, instead of being able to bill 58573?


He states:
The Veress needle was introduced into the peritoneal cavity at a straight angle without difficulty. A saline drop test was performed to validate intraperitoneal placement. The pneumoperitoneum was established with CO2 gas to the pressure of 15 mm Hg. An 8 mm trocar was inserted into the abdomen. Intraabdominal placement was confirmed with laparoscope.

Pneumoperitoneum was obtained with CO2 gas. Lateral port placement measurement was undertaken. Three further 8 mm robotic trocar ports were then placed in a parallel fashion to the umbilical port with a spacing of 8 cm; two port to the patient left and one ports to the patient right. An assistant port was then triangulated in the right upper quadrant 7 cm from the midline and left lateral port without difficulties. Assurance of trocar centering was confirmed laparoscopically. The robot was then docked to the patient without difficulties and anatomy targeting was undertaken. Bipolar forceps advanced into arm #1. An advanced vessel sealer was introduced in arm #2; monopolar scissors were advanced into arm #4. This was done under direct visualization laparoscopically. Sterile scrub was then broken and attention was turned to the robotic console. An initial inspection of the pelvis revealed the above findings. The bilateral ureters were identified transperitoneally and found to be away from the operative field.

The bilateral fallopian tube mesosalpinx was then desiccated and transected using the vessel sealer up to the level of the cornu. The bilateral fallopian tubes were left attached to the uterine corpus. The bilateral utero-ovarian ligaments were desiccated and transected using the vessel sealer.

The bilateral round ligaments were desiccated and transected using the vessel sealer. The bilateral broad ligaments were progressively desiccated and transected down to the level of the uterine arteries. The uterine arteries were then skeletonized. The posterior leaf of the broad ligament was then opened up bilaterally and the bilateral ureter course was identified retroperitoneally and found to be away from the Rumi colpotomy cuff. The bilateral uterine arteries were then desiccated and transected using the vessel sealer. A bladder flap was created anteriorly and the bladder was dissected off of the vagina using monopolar scissors. A colpotomy was then performed circumferentially pericervically using the monopolar scissors and using the Rumi colpotomy ring as a guide. The uterus with cervix and bilateral fallopian tubes was too large to be delivered vaginally. The specimen placed in the upper abdomen for later retreival.

The vaginal cuff was then closed laparoscopically robotically with a running stitch of 2-0 V lock suture. The pelvis was irrigated with normal saline. All pedicles were inspected. No bleeding was noted.

Gloves were changed and attention was turned to the abdomen once again. The da Vinci was undocked from the patient without difficulties.

Small minilaparotomy phanenstiel incision made, about 4 cm. This was carried down to the fascia. Fascia incised and extended. Peritoneum identified and entered bluntly. Small alexis retractor placed. Uterus was identified and brought to the incision. The uterus was morcelated until it could be removed through the incision. The alexis retractor removed and the fascial layer closed with 0 vicryl. Next subq was closed with 3-0 monocryl. Skin was closed with 4-0 monocryl.

The abdomen was then desufflated and all instruments were removed from the abdominal cavity. All skin incisions were closed using 4-0 Vicryl suture in a subcuticular fashion. Steri-strips and bandages were placed.

The patient was taken out of the dorsal lithotomy position, she was awakened from anesthesia and extubated. She was taken to the recovery room in stable condition. She tolerated the procedure well. Sponge, lap and needle counts were correct at the end of the procedure.


Disposition: PACU - hemodynamically stable.

Condition: stable


Thank you, Cathy, CPC, COBGC
Saint Francis Health System
 
cubbiecatz said:
I want to make sure I am coding my providers surgery correctly; it was Robotic assisted Total Laparoscopic Hysterectomy with bilateral Salpingectomy with mini-laparotomy. Per the path report the weight is 309 grams.
Everything detached laparoscopically. Mini-laparotomy performed to remove the specimens. Based on all the above information do I have to code this as 58150 because he made a small incision, instead of being able to bill 58573?


He states:
The Veress needle was introduced into the peritoneal cavity at a straight angle without difficulty. A saline drop test was performed to validate intraperitoneal placement. The pneumoperitoneum was established with CO2 gas to the pressure of 15 mm Hg. An 8 mm trocar was inserted into the abdomen. Intraabdominal placement was confirmed with laparoscope.

Pneumoperitoneum was obtained with CO2 gas. Lateral port placement measurement was undertaken. Three further 8 mm robotic trocar ports were then placed in a parallel fashion to the umbilical port with a spacing of 8 cm; two port to the patient left and one ports to the patient right. An assistant port was then triangulated in the right upper quadrant 7 cm from the midline and left lateral port without difficulties. Assurance of trocar centering was confirmed laparoscopically. The robot was then docked to the patient without difficulties and anatomy targeting was undertaken. Bipolar forceps advanced into arm #1. An advanced vessel sealer was introduced in arm #2; monopolar scissors were advanced into arm #4. This was done under direct visualization laparoscopically. Sterile scrub was then broken and attention was turned to the robotic console. An initial inspection of the pelvis revealed the above findings. The bilateral ureters were identified transperitoneally and found to be away from the operative field.

The bilateral fallopian tube mesosalpinx was then desiccated and transected using the vessel sealer up to the level of the cornu. The bilateral fallopian tubes were left attached to the uterine corpus. The bilateral utero-ovarian ligaments were desiccated and transected using the vessel sealer.

The bilateral round ligaments were desiccated and transected using the vessel sealer. The bilateral broad ligaments were progressively desiccated and transected down to the level of the uterine arteries. The uterine arteries were then skeletonized. The posterior leaf of the broad ligament was then opened up bilaterally and the bilateral ureter course was identified retroperitoneally and found to be away from the Rumi colpotomy cuff. The bilateral uterine arteries were then desiccated and transected using the vessel sealer. A bladder flap was created anteriorly and the bladder was dissected off of the vagina using monopolar scissors. A colpotomy was then performed circumferentially pericervically using the monopolar scissors and using the Rumi colpotomy ring as a guide. The uterus with cervix and bilateral fallopian tubes was too large to be delivered vaginally. The specimen placed in the upper abdomen for later retreival.

The vaginal cuff was then closed laparoscopically robotically with a running stitch of 2-0 V lock suture. The pelvis was irrigated with normal saline. All pedicles were inspected. No bleeding was noted.

Gloves were changed and attention was turned to the abdomen once again. The da Vinci was undocked from the patient without difficulties.

Small minilaparotomy phanenstiel incision made, about 4 cm. This was carried down to the fascia. Fascia incised and extended. Peritoneum identified and entered bluntly. Small alexis retractor placed. Uterus was identified and brought to the incision. The uterus was morcelated until it could be removed through the incision. The alexis retractor removed and the fascial layer closed with 0 vicryl. Next subq was closed with 3-0 monocryl. Skin was closed with 4-0 monocryl.

The abdomen was then desufflated and all instruments were removed from the abdominal cavity. All skin incisions were closed using 4-0 Vicryl suture in a subcuticular fashion. Steri-strips and bandages were placed.

The patient was taken out of the dorsal lithotomy position, she was awakened from anesthesia and extubated. She was taken to the recovery room in stable condition. She tolerated the procedure well. Sponge, lap and needle counts were correct at the end of the procedure.


Disposition: PACU - hemodynamically stable.

Condition: stable


Thank you, Cathy, CPC, COBGC
Saint Francis Health System
Click to expand...
Per the opinion by AHA, since there was a separate incision made, this would be coded 58150.
My opinion differs, and would code this 58573.
I code as converted to open only if actual surgery is taking place through that open abdominal incision.
 
Just to note that the guidance provided by the AHA HCPCS Coding Clinic from 2019 conflicts with the advice published in
the July 2021 edition (page 5) of CPT Assistant. The AMA clarified their position on this issue by stating:

Current coding recommendations for laparoscopic procedures converted to open procedures are as follows:

  • Appropriate coding may vary on a case-by-case basis, depending on the specific circumstances in each case.
  • If majority of the procedure were performed laparoscopically, and the structures removed laparoscopically, the laparoscopic code for the service would be reported.
  • If majority of the procedure were performed laparoscopically, and the structures removed laparoscopically, but due to organ size a mini-laparotomy had to be performed for organ removal, the laparoscopic code for the service would be reported. If the additional work of the minilaparotomy were significant, it may be reported with modifier 22, Increased Procedural Services.
  • If the laparoscopic procedure were started (minimal work performed) and immediately converted to and completed as an open procedure due to, as an example, patient safety issues, only the open procedure would be reported.
  • Note that individual third-party payer, facility reporting, and reimbursement policies may vary.
 
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