Wiki VNOTES BSO

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mrf4d

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Hello, recently my urogynecologist has begun using VNOTES to perform a vaginal endoscopy BSO. She first performs a vaginal hysterectomy and AFTER the uterus is removed, then proceeds with VNOTES BSO. My understanding from researching VNOTES technology is it's another way of performing a "laparoscopic" surgery without having to place the abdominal ports - so shorter recovery time, less invasive, etc. I've been in touch with one of the VNOTES reps via my provider and he has suggested billing LAVH/BSO. Technically, my doctor and I both agree this doesn't accurately describe what she does. I'm wondering if a better coding solution would be to code the TVH with CPT 58661? Has anyone else had any experience with this or know if ACOG has provided any guidance yet on how to bill for this new technology?
 
My research has lead to using the vaginal codes unless abdominal ports are placed. So your procedure would be total vaginal hysterectomy with BSO for 58262 (assuming < 250gms). While I personally may not agree with that advice, absent a guidance from ACOG, I will continue to use the vaginal codes. If abdominal ports are placed with a portion of the surgery (not just removal of specimens) through vagina, I would use the laparoscopic assisted vaginal codes. If entire surgery done through laparoscopic abdominal ports, I would use the laparoscopic codes.
I would not code 58661 in your example. Per Codify, the full description of 58661 is:
First, the provider places the patient in the dorsal lithotomy position. He then preps and drapes the abdomen and administers a general anesthetic. The provider places a uterine manipulator through the cervix so he can move the uterus around during the surgery. The provider enters the abdominal cavity near the belly button using a Veress needle or an open incision to place a laparoscope. The provider insufflates the abdomen with CO2 gas to create a pneumoperitoneum and then puts the patient into the Trendelenburg position. He then makes small incisions around the abdominal area to insert trocars to better view the operating site and insert surgical tools.


If the provider is performing robotic surgery, he docks the robot to the laparoscope at this time. The provider isolates the infundibulopelvic ligament and protects the ureter while he controls bleeding from the ovarian vessels. Next, he separates the ovary and fallopian tube from the round ligament and any adhesions that might be present. Once the ovary and tubes are free, the provider removes them from the abdomen through one of the trocar sites or he makes a small incision in the vaginal wall and removes them through that. If the ovary contains a cyst, the provider will place it in a sterile bag so that he can aspirate and deflate it without spilling the contents into the abdominal cavity. He repeats this procedure on the other side for a bilateral procedure. He may remove just the ovary or fallopian tube or both on one side or both. He then irrigates and deflates the abdominal cavity and removes all instruments and trocars. He closes the trocar site fascia and skin and removes all instruments from the vagina.


 
mrf4d said:
Hello, recently my urogynecologist has begun using VNOTES to perform a vaginal endoscopy BSO. She first performs a vaginal hysterectomy and AFTER the uterus is removed, then proceeds with VNOTES BSO. My understanding from researching VNOTES technology is it's another way of performing a "laparoscopic" surgery without having to place the abdominal ports - so shorter recovery time, less invasive, etc. I've been in touch with one of the VNOTES reps via my provider and he has suggested billing LAVH/BSO. Technically, my doctor and I both agree this doesn't accurately describe what she does. I'm wondering if a better coding solution would be to code the TVH with CPT 58661? Has anyone else had any experience with this or know if ACOG has provided any guidance yet on how to bill for this new technology?
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In fact this would be an excellent question to present to ACOG for an opinion. You can do so by going to: https://www.acog.org/practice-management/coding/ask-a-coding-question and following their instructions.
 
I had submitted a question to ACOG that incorporated this, although my question was not this directly. The correct coding for vNOTES hysterectomy when using laparoscopic tools via vagina only (no abdominal ports) is to use vaginal hysterectomy codes.
In my case - vNOTES total hysterectomy with tubes was performed. Additionally, an ovarian cystectomy was performed (physician leaving ovaries in situ due to age of patient).
This was my question and their response:
QUESTION:
One of my providers has very recently started performing vNotes procedures in which the surgery is done through the vagina with laparoscopic tools. My research thus far has led me to using total vaginal hysterectomy codes if there is no trocar or camera in the abdomen, and laparoscopic assisted vaginal hysterectomy codes if there is an abdominal camera or trocar placed.
In the specific case attached, there was a total vaginal hysterectomy (<250gm) with bilateral salpingectomy, so 58262. The provider also performed a left ovarian cystectomy through the same vaginal access. Neither 58925 for an open cystectomy nor 58662 for a laparoscopic cystectomy seem quite correct. I am considering:
1) unlisted 58679 with comparison 58662
2) just 58262 with -22 modifier
Would you recommend either of these or a third option?
Any assistance or advice is greatly appreciated!!

RESPONSE:
In this case, we would recommend reporting 58262-22. The ACOG Committee for Health Economics and Coding (CHEC) has indicated that the work of the vNOTE hysterectomy is very consistent with the vaginal hysterectomy codes--only with an additional tool used. The 22 modifier would be the best option to report the ovarian cystectomy, although some payers may be resistant to additional reimbursement in this case since the work of removing the ovary would already be included 58262, had it been performed.

This does follow the same logic as when the daVinci robot started being used. ACOG determined no additional CPT or payment for robotic hysterectomy vs traditional laparoscopic hysterectomy since it is only a difference in the tool used. The same really applies here. The physician is doing the surgery through a vaginal approach, just with different tools.
 
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