# Uterus weight for hysterectomy



## AlyssaM907 (Dec 14, 2017)

So I've been trying to find clarification online...but haven't found anything so far. 
I'm new to OB/GYN coding and have found I have a problem reading a little too much in between the lines and making sure my codes fit EXACTLY. With that being said: 
On my path report the pathologist states she received "multiple fragments of uterine tissue that together weigh 367g and measured...."
My question: 
I know for LAVH codes (and a few others) they are dependent upon the weight of the uterus...as the path statement above states, it's not JUST the uterus weight they listed but rather the TOTAL weight of the tissue. Would I just code to the lesser 58552 (uterus less than 250g) if the path report doesn't specifically state the uterus itself was 250g+?

I'm billing for our private dr who did this as an outpatient procedure at a big hospital here, the hospital did the path. I don't know if we can request going forward that the uterus be weighed independently for coding purposes??? 

Thanks in advance!! I'm sure I'll be seeing you guys around quite frequently now that I've found this forum! Excited to learn as much as I can!


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## jhanmer83 (Dec 27, 2017)

Here's an example of one of my path reports. It was coded as over 250g. If the path report or op note don't mention the weight, I would default to the lesser charge. "Uterine tissue" would all be included in the total weight of the uterus, so the higher charge would be appropriate based on the info provided.

"Received in a container of formalin, labeled with the patient's name, patient demographics and "uterus, bilateral fallopian tubes and ovaries" is a 489 g nodularly distorted uterus which is 11.7 cm from superior to inferior, 12 cm from cornu to cornu and 7 cm from anterior to posterior. The uterus has attached right and left fallopian tubes and ovaries."


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## AlyssaM907 (Dec 29, 2017)

*Thanks for the reply - conclusion our office came to...*

Thank you for your reply. After going through a few more reports from different hospitals we found that 2 specific pathologists just weren't notating the independent weight of the uterus, they would lump them all together and in short would read "received sample labeled with patient name including uterus, fallopian tubes and ovaries with a weight of 356g". I basically assumed that unless the weight is clearly notated for specifically just the uterus that I would code to the lesser just to be cautious. We did contact the hospital's path office and requested that they ask the 2 pathologists to start including a uterine weight separate from a mass collective measurement so we will have a better opportunity going forward to code the procedures more definitively (and obviously for my purposes collect any extra revenue that may be available).


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## csperoni (Dec 29, 2017)

Yes, you definitely may need to educate a pathologist or 2 regarding why uterus weight separately is required.  Sometimes I will get a pathology report with no weight noted at all.  Provided I contact the pathology department timely, they will then send an amended report with the information.


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