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submucous leiomyoma removed in office

  1. Default submucous leiomyoma removed in office
    Medical Coding Books
    Pt presented with complaint of: 'tissue hanging from her vagina that's stuck.' Pt is She is 2 mo. s/p a hysteroscopy, D&C, & rollerball on 5/18 d/t menorrhagia and fibroids. Sono showed: large fibroid (8.18, was 7.65 mm at largst last sono on 4/11) seen, EC was 9.1 mm, very difficult to distinguish d/t fibroid artifact.

    Upon Exam IN OFFICE w/no anesthesia a large mass of soft fleshy rubbery material was removed from cervix with ring forcep, sent to path urgent. She likely had a prolapse of a submucous fibroid. Pathology confirmed it was 218.0 submucous leiomyoma of uterus .

    Looking at past questions, I offered my doc CPT code 58145 as best fit for this, or if she was uncomfortable with this, go with unlisted procedure code 58999 and send with records. She doesn't want either, and insists there must be something else. Can anyone offer anything else for her? Thank you.

  2. Default
    If it was not a hysteroscopic removal?! Pathology report final. You are correct with 58145 - in either way- if it is less than 250grms or less, OR if the weight was not recorded, then the removal of surface myoma would fit for this submucous myoma (which was pedenculated and protruding on to the vagina through the cervix or whatever)- vaginal approach.
    No matter whether a knife or scissors or ring forceps was used or was it removed easily or with difficulty- It is a removal of fibroid uterus for coding
    When we have a code, why would we go for unlisted?

  3. Default
    I agree! My doc was resistant to using 58145 saying it "wasn't that extensive a procedure." She wanted "proof" this was correct choice to the point of contacting other area OB offices to query how their doc's and billers would code this. (sigh) The other offices had not encountered this in an office setting, thus she was still uncomfortable with 58145 so I offered the "unlisted" as last resort. Thank God for AAPC folks like you who can help me in these situations! Grateful thank you, as always.

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