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Hysterectomy w exploration of ureters

  1. #1
    Default Hysterectomy w exploration of ureters
    Medical Coding Books
    One of our OB/GYN's is starting to note on his his Hysterectomy op reports "exploration of ureters". All I am reading in the op report regarding this is "The ureters were trace with good peristalsis" This doesn't seem to be enough for me to even consider 52000 and so have not coded it separately. Any guidance is greatly appreciated.


  2. #2
    Idaho Falls, Idaho
    You can not code that seperately, just like you can't code a dx lap and then a lap surgery. The exploration doesn't really mean anything because they are taking it out, and the lab will do their own pathology.
    Tesja Erickson, CPC, CPMA COBGC, CEMC
    The Coding Surgeon
    Medical Documentation & Coding Consultant
    2012 AAPC Idaho Falls Chapter President
    2011 AAPC Idaho Falls Chapter President-Elect

  3. #3
    I wouldn't code it separately, either. Sounds like maybe your doc is doing the ureter exploration as a routine part of his hysterectomy, maybe checking his work, and surgeons don't get reimbursed separately for checking their work. The 52000 is listed in CPT as a separate procedure, and I'm pretty positive it's going to be bundled with your hysterectomy code no matter what.

    Hope that helps.

    Becky, CPC

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