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Thread: Need help with a procedure code

  1. #1

    Unhappy Need help with a procedure code

    AAPC: Back to School
    Pt had a Myomectomy (58146) & the physician states he also did a Excision of a endometrial cyst which measured 4x3x1cm I feel the code is 49203. But would like another opinion from my fellow CPC's. Please any advise would be greatly appreciated.

    Sincerely, Sharon CPC

  2. #2


    Could you please post the op notes completely. There are some improtant points to be known in this.
    It could be a fibroid with cystic changes by degeneration- like RED DEGENERATION which shows cystic character. If so, it could only be considered as yet another sub mucous or intramural myoma and it is bundled in the 58146.
    To validate for 49203, a tumor/cyst endometrioma , should be in the abdominal cavity-side, like, serosal side of the uterus, or the peritoneum, broad ligament , uterine adenexa, utro-sacral septum or to other pelvic ligament or structure.
    This cyst is intramural/ luminal/ submucous of the uterine cavity side. So does not merit the code 49203.
    I feel that you would be fine with 58146.
    If more work and time consuming and extra efforts taken, you could append with Modifier-22.
    Thank you

  3. #3

    Default part of op-note pertaining to the question see if this helps

    The periumbilical cysts were then excised.The subcutaneous tissure @ the level of Scarpa's was reapproximated with interrupted 3-0 plain around the umbilicus.This was carried in an terrupted fashion to reapproximate Scarpa's of the umbilicus as well.The inferior aspect of the incision was then reapproximated with interrupted 3-0 plain. The umbilical skin was then reapproximated with interrupted 3-0 Vicryl stitch.The skin cephalad & caudal to this were reapproximated with staples.

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