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Lap Para Metrectomy; S/P LAVH/BSO

  1. #1
    Red face Lap Para Metrectomy; S/P LAVH/BSO
    Medical Coding Books
    Which is most important, the procedure or the approach?? Surgeon performs a 58571 in May. In July, he takes the patient back to OR and bills a 58548-52. He is now billing a Laparoscopic radical parametrectomy, upper vaginectomy, bilateral pelvic lymph node dissection. Cystotomy and repair (incidental). This is the scenario:

    Procedure Code(s) Reported by Provider
    58548 – 52 Laparoscopy, Surgical Radical Hysterectomy, w/bilateral total pelvic Lymphadenectomy and para-aortic lymph node sampling, with removal of tubes(s) and ovary(s).

    Diagnosis Code(s) Reported by Provider
    180.0 Malignant Neoplasm Endocervix

    Procedure Code(s) Supported by Documentation
    57109 -Vaginectomy; Partial removal of Vag Wall, with removal of paravaginal tissue (radical vaginectomy; with bilateral total pelvic Lymphadenectomy and para-aortic lymph node sampling
    51860 Repair of Bladder Wound
    49321 Laparoscopy Surgical w/biopsy

    Diagnosis Code(s) Supported by Documentation
    233.39 Carcinoma in situ Other female genital organ
    233.2 Carcinoma in situ other and unspecified parts of uterus

    The Surgeon feels that the Lap-Hyst code reduced best fits the procedure since there is no code for the parametrectomy and the 57109 is an open procedure. Any other views?

  2. Default
    I too lean for the 58548- 52 because it is laproscopic and open procedure cannot be coded in place of lapro. It is a lapro surgery less of uterus (and cervix)
    and hence can fit for reduced service with laproscopy.

    49321 can be reported, as per my openion, because it is not a component for the procedure. I would rather name it as an accidental to the procedure ( an anticipated complication which was unavoidable). It is a distinct and significant procedure on to a different organ, though the site of incision and the session are the same.
    So I feel that 49321-59 is qualified with the support of a ICD-9 CM 867.1 and an E code E870.0 ,showing accidental injury during the time of surgery.

    For the main primary code ,how did you arrive at those insitu code; do you have the path report?
    Was the cervix left behind during the previous hysterectomy for the doctor to code endocervix malignancy code? The picture is not clear.

  3. #3
    Default S/p lavh/bso
    Yes. The path report also stated "adenocarcinoma in situ, endocervix in May, when the uterus and cervix were removed. Now in July the dx on the op-note and path report is "malignant neoplasm of cervix".



    1. Anterior vagina and parametrium, excision:
    - Benign fibrous tissue with focal giant cell reaction and chronic
    - Negative for malignancy.
    - Focal endometriosis.

    2. Posterior vagina and parametrium, excision:
    - Benign squamous mucosa, negative for dysplasia or malignancy.
    - Giant cell reaction, hemosiderin and chronic inflammation.
    - Focal endometriosis.

    3. Pelvic lymph node, excision:
    - Fourteen lymph nodes, negative for metastatic malignancy (0/14).

    Malignant neoplasm of cervix.

    Specimen #1 is labeled with the patient's name and "anterior vagina and
    parametrium." Received in formalin is an irregular red-tan fibrofatty
    tissue, 6.2 x 2.8 x 1.8 cm. At one end, there is a strip of interpreted
    epithelium, 1.5 x 0.3 cm. I ink the outer surfaes black. ES

    Specimen #2 is labeled with the patient's name and "posterior vagina
    and parametrium." Received in formalin is an irregular fibrofatty
    tissue, 6 x 3.3 x 1.4 cm. On the surface, there is a strip of
    epithelium, 4.5 x 0.5 cm. I ink the interpreted surgical margins
    black. ES

    Specimen #3 is labeled with the patient's name and "pelvic lymph
    nodes." Received in formalin is a 5 x 5 x 3 cm aggregate of yellow
    fatty tissue. All lymph node candidates are submitted.

    PTT/hh 07/12/11
    Cassette verification identification by KV

    1A-G - anterior vagina and parametrium sequentially submitted, surface
    to deep
    2A-G - posterior vagina and parametrium
    3A-C - lymph node candidates
    3D-J - seven lymph nodes, one per block
    3K-L - one lymph node

    26 blocks, 26 H+E slides

  4. Default
    The malignant neoplasm endo cervix /cervix do not fit for this scenario, because cervix is not there to code for the current situation.

    The final surgical path report says there was no malignancy in any of the specimens. It says Endometriosis- Endometriosis do not merit for neoplasm codes. Its code range is
    617.x series. You can go for a V code 71.1 as the primary code too, observation for suspected malignant neoplasm.
    Yet another personal history code of malignant neoplasm, ( which is not there now).
    However the diagnoses which merit, yet could justify the procedure's medical necessity as well. No need for fear of denial I believe.

  5. #5
    Default S/p lavh/bso
    Thank you so much. You have validated all logic. And I really, appreciate the prompt response. Have a great week!!

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