What was the diagnosis and indication for hysterectomy. If you had given the op note it would have been better.
The doctor would have done the plication of the uterosacral ligament when he has the diagnosis of Prolapse uterus with rectocele /enterocele.
So when there was a prolapse diagnosis (along with the reason for hysterectomy), there are two surgery at hand for him to decide-1. An Obliterative Surgery or 2. A Reconstrcutive Surgery. When he intended for reconstructive surgery to restore the normal anatomy and give the best chance for normal quality of life along with Hysterctomy,- restoration of the support to the vaginal apex is needed - either one of these common procedures that can do this job are : the Plication (fixation) of uterosacral ligament, Sacral colpopexy, Sacrospinous ligament fixation.
So I would go for Hysterectomy code and vaginal apex restoration code 57425.
Hysterctomy code alone is not sufficient to address the amount of work done by the surgeon.
Our hysterectomy code sets are not addressing many of the work done along with, by the surgeons , laparoscopic in particular.
So in short : if the surgeon did an OBLITERATIVE surgery along with hysterectomy - Hystectomy code alone would be enough . If he did a RECONSTRUCTIVE SURGERY ( what he has done now here), along with Hysterctomy code, I would report 57425 also.
The surgeonâ€™s diagnosis and the intended RECONSTRUCTIVE SURGERY should be documented in his report / or operative note clearly.
Note: Uterosacral ligament placation/ colpopexy can be undertaken with or with out intended hysterectomy . There need not always be a hysterectomy to be accompanied.
I do not know how the payers do. This is all about the medical necessity and the risk adjustments concepts I brought forth.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join