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Total abdominal hysterectomy with pelvic mass removal

  1. #1
    Exclamation Total abdominal hysterectomy with pelvic mass removal
    Medical Coding Books
    Good evening

    I need help please from the gyn professional expert. The doctor spent many hours on this case and I want to make sure that I code to the highest specificity so that he gets paid what he deserves.

    Pre-op Dx: Pelvic pain. Procedure authorized by Medicare exploratory laparotomy
    Post-op Dx: Left adnexal mass, possible borderline mucinous cystadenoma. 2 Fibroid Uterus

    Procedure Preformed
    1. Examination under anesthesia
    2. Exploratory laparotomy
    3. Removal of pelvic mass.
    4. Total abdominal hysterectomy and bilateral salpingo-oophorectomy.

    Here is the main part of the op report:
    This mass was then removed in its entirety and was sent to pathology for frozen section in its entirety as well. The mass itself ended up filling 3.6kg by report from the pathologist and also the pathologist noted that the initial preliminary frozen section revealed possible borderline mucinous cystadenoma with a possibility of a cystadenocarcinoma on further sections. Once determining that the patient had a borderline tumor, a decision to move forward with an abdominal hysterectomy and removal of the remaining adnexal was made by me. The uterus itself was somewhat enlarged for a postmenopausal woman, and she did have postmenopausal bleeding, and therefore, it was also felt appropriate to remove her uterus at the same time.

    I have coded: 789.30, 218.9, and 49000-57 (modifier), 58150-59 (modifier), 49205-59 (modifier)

    Thank you!!

  2. #2
    I'm definately not an expert, just studying for my OB Cert., but my understanding of CPT 49000 is usually included in with the more complex service. Refer to '09 OB/Gyn coding companion page 57. I agree with your other codes.
    Good luck,

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