# Remnant Cervical Tissue



## KVerthein (Dec 20, 2010)

I am looking for some assistance with coding for "Removal of Remnant Cervical Tissue."  I have found topics related to "REPAIR of", but nothing referencing "Removal of.."

Please help!

Thanks,
Kristy


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## preserene (Dec 20, 2010)

Hi sorry, we really need the Op notes  for this to assign


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## KVerthein (Dec 20, 2010)

Operative Indications: 
53 y/o gravida 3, para 3 status post vaginal hysterectomy w/colporrhaphy several years ago who reports dyspareunia point tenderness in the apex of the vagina during intercourcse.  The patient has recently been treated for vaginal atrophy w/some improvemtn, although the patient reports there is still tenderness at the area and desires removal of the cuff remnant. 

Operative Technique:
Patient was brought to the OR.  A time out was performed.  She was prepped and draped in a normal sterile fashion in the dorsal lithotomy postion.  Her legs were placed in candy cane stirrups.  Initially it was through that a LEEP instrument would be good to remove the remnant; however, upon revisualization of the vaginal cuff and considering the narrowness of her vagina this was not done.  Instead a 15-blade scalpel was used to excise the less than 5-mm remnant.  Minimal estimated blood loss was present.  Pressure was held at the area of bleeding and a small amount of Monsel was placed at the area of the excision for hemostasis.  Please not that prior to the beginning of the case bimanual examination was done as well as emptying the bladder.  The vaginal canal was reinspected after removal of the remnant.  The mesh was palpated at the posterior aspect of evidence of room for a surgical expansion of the vaginal length or width.  The case was then ended.  The sponge, lap and needle counts were correct times two.  Please note that also prior to the beginning of the case a bolus solution of lidocaine with epinephrine 1:100,000 was used and less than 1 ml was injected in the vaginal cuff remnant that was to be removed.


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## preserene (Dec 20, 2010)

Status  Post Vaginal  Hysterectomy wih colporrhaphy done many years ago- that means  the Cervix is totally removed along with the body of the uterus, There is no cervical stump left behind. So it is NOT cervial tissue. 
Colporraphy done with a Mesh left.  So the tissues could be the redundant portion tag of the vaginal tissues (which could happen while the process of healing of the approximated site of vaginal incisional margins) or a new growth of tissue. there is no possibility of any other tissue jutting out there to merit its presence.
As such I would give 57135 excision of tumor/cyst or any vaginal core or mass of tissues , until and otherwise the pathology report comes different.
Does this help you


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## btadlock1 (Dec 21, 2010)

We're not at liberty to decide what was actually removed; we have to code off of the information provided on the op note. That being said, if I were coding this, I'd assign:
57550 Removal of residual cervical stump, vaginal approach, with diagnosis code 625.9 (Pain, female genital organ). Also noteworthy is 622.8, which is what you find when searching "Stump, cervical" in tha alphabetic section. I'm not sure which one is a better fit, though.

The physician goes as far as to nearly spell out what they're removing - it's a remnant cuff from the previous colporrhaphy (i.e. leftover cervical stump). Yes, ideally, when a colporrhaphy is performed, there shouldn't be any remnants. However, it's obvious by the fact that there are specific CPT and ICD-9 codes pertaining directly to this issue, that leaving remnants of cervix behind *does* happen on occasion. The doctor didn't refer to the tissue as a polyp, or lesion, or mass. The verbiage used was "cuff remnant, vaginal cuff, vaginal atrophy" - in fact, the word "remnant" was used 5 times - it's not exactly a long note. That tells me that the doctor thought it was important to point out that he was removing something left over from the removal of something else. I don't believe it would be appropriate to decide that the physician was mistaken and code something else in lieu of a pathology report, or _some_ form of documentation that supports an alternate theory on the patient's anatomy/condition.


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## preserene (Dec 21, 2010)

Hi  brandi,
You  have mistaken my whole concept.
I am not imagning  the scenario but analyzing the scenario.
POST VAGINAL HYSTERECTOMY, MEANING, ‘THERE IS NO CERVICAL STUMP LEFT BEHIND' As for vaginal hysterectomy, there is no procedure of removing the body of the uterus  leaving the cervix in position.  We do remove Cervix and body of the uterus enmass. To get to know this, do we need this treating doctor to write down the procedure of  (status) vaginal hysterectomy?

The actual procedure of vaginal hysterectomy is in finger tips with me because I have done  thousands of vaginal hysterectomy. CERVICAL STUMP means the cervix without body of the uterus left behind a procedural plan; ie when doing subtotal hysterectomy . That remaining portion of the cervix is called CX STUMP. The doctor very well knows it and they document even after just a pelvic/bimanual examination. If it was what she felt was a stump she would have documented definitely as “CX STUMP”. 
What she meant cuff here, means vaginal cuff ie vaginal tissues. That is the cuff  or portion of vagina or the tissues of vagina I am talking about. I am aware of  what is vaginal cuff.(Cuff of vagina means a portion or part or core or tissues of vagina. For eg, when they do abdominal hysterectomy if they intend to remove vaginal tissues along with, they say ‘'come on let us remove a cuff of vagina too!”).
 Any one would know what the structure is, there now after vaginal/abdominal hysterectomy. Let us not go into the fundamentals which should be clear by now.
Next: colporrhaphy means repair of the “colpos” meaning “Vagina”- vaginal repair. I know the whole steps of the procedure and what is being done. Usually there will not be any redundant part left because it is clearly visualized just in front of us and trim the edges and suture it approximately.  But now with mesh placement   some remnants of the marginal tissues of the vagina are possible to remain as such (if not as granuloma) . this is what  is meant as remnants or redundant tissues of the vagina. That cuff of vagina jutting as redundant tissues needs  to be removed  when it bothers .
Next: The pervious diagnosis we do not know but the doctor knows. It could be for eg, any neoplasm of the cx or uterus or even intraepithelial noeplasia. So at this age of 53, with the unknown previous diagnosis and a core of vaginal tissues ,a cuff of vaginal tissues or a mass of  tissues cannot be named otherwise until the path report comes and the doctor names it . That is not the issue here. I did not mean to wait for the path report to assign a CPT code NOW
The issue is to which code to assign now. I gave my opinion of assigning a code  with a number which I still stand for it
Now, the tissues or tags that is the remnants  So I gave my opinion of assignment.

Next I would like to make it understandable to you-  that my appearance often in the forum is to gather knowledge and to extend my knowledge& experience with my vast 30 years OBGYN specialist withM.D. & medical  knowledge in a  most BENIFICIAL, USABLE PRACTICAL  AND CLINICAL WAY, but NOT FOR ARGUMENT OR AUDITING PURPOSE. You audit it audit. 
But please do not cross or use  the facts of medicine  to make it obsolete for your auditing purpose. Some of you have mistakenly painted me dark. 
Then, medical facts are facts; procedures are procedures; techniques are techniques; critical thinking  and  analyzing those facts and procedures I learnt and gathered  throughout my professional career for a better understanding and for a culminating beneficial outcome should be always welcome. Not for who win or who loose.
Well it is high time I get  to a long leave from you all.


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## btadlock1 (Dec 22, 2010)

preserene said:


> Hi  brandi,
> You  have mistaken my whole concept.
> I am not imagning  the scenario but analyzing the scenario.
> POST VAGINAL HYSTERECTOMY, MEANING, ‘THERE IS NO CERVICAL STUMP LEFT BEHIND’ As for vaginal hysterectomy, there is no procedure of removing the body of the uterus  leaving the cervix in position.  We do remove Cervix and body of the uterus enmass. To get to know this, do we need this treating doctor to write down the procedure of  (status) vaginal hysterectomy?
> ...



You misunderstand me. There is a high likelihood that you are 100% correct, and the procedure happened precisely as you described it, for the specified reasons. The problem here, is that none of that is *documented.* To draw a simple and reasonable conclusion about the circumstances of an encounter is often necessary. You have gone quite a bit further here. Perhaps it is your vast knowledge and experience that is driving your hubris, and allowed you to, in essence, think *for* the doctor - describing conditions that aren't necessarily mentioned, and defining procedure details that have not been specified, no matter how much improvisation is required, on your part. 

As a coder, it is your job to code the encounter *based on the medical record documentation*. We are *not* told to _embellish _the scenario with specific information that was not made abundantly clear *by the physician*, no matter how correct you may be. We do not possess psychic abilities; we're not in the business of reading doctors' minds and providing official interpretation of their thoughts. If you wish to assign a more specific code than documentation supports, you have the doctor clarify the documentation by appending the documentation. Period. Let the doctors speak for themselves.


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## preserene (Dec 22, 2010)

Here we have the OP notes and documentation by the Physician. Please read that again.

"Operative Indications: 
53 y/o gravida 3, para 3 status post vaginal hysterectomy w/colporrhaphy several years ago who reports dyspareunia point tenderness in the apex of the vagina during intercourcse. The patient has recently been treated for vaginal atrophy w/some improvemtn, although the patient reports there is still tenderness at the area and desires removal of the cuff remnant. 

Operative Technique:
Patient was brought to the OR. A time out was performed. She was prepped and draped in a normal sterile fashion in the dorsal lithotomy postion. Her legs were placed in candy cane stirrups. Initially it was through that a LEEP instrument would be good to remove the remnant; however, upon revisualization of the vaginal cuff and considering the narrowness of her vagina this was not done. Instead a 15-blade scalpel was used to excise the less than 5-mm remnant. Minimal estimated blood loss was present. Pressure was held at the area of bleeding and a small amount of Monsel was placed at the area of the excision for hemostasis. Please not that prior to the beginning of the case bimanual examination was done as well as emptying the bladder. The vaginal canal was reinspected after removal of the remnant. The mesh was palpated at the posterior aspect of evidence of room for a surgical expansion of the vaginal length or width. The case was then ended. The sponge, lap and needle counts were correct times two. Please note that also prior to the beginning of the case a bolus solution of lidocaine with epinephrine 1:100,000 was used and less than 1 ml was injected in the vaginal cuff remnant that was to be removed."

There is NO CERVICAL STUMP MENTIONED.I know it for sure that s(he) meant very clearly not to mention so. Nor cervical tissue mentioned. Again and again "CUFF of vagina is stated.
Cuff of vagina is the terminology  exclusively for vagina not for cervix
That is why I reinstated what is in realty too in the procedure.
When there is no mention of cervical stump also in the documentation, you can not imagine "Cervical stump" to be there in th scenario and code it.
cervix is the hanging portion of the uterus. It is can be left as a stump (in abdominal Hysterectomy or removed enmass in hysterectomy procedures.
There is no terminology of cuff of cervix in the medical realm- it is either cervix or cervical stump or cervical tissues ,polyp, mass or Cx conization and stuff like that
It is not going for extra miles but it is medical facts I brought forth. 
If you are beyond, fine. Let these informations be useful for others to know and they analyse my assignment of the code is not incorrect and to know IT IS NOT CERVICAL STUMP. I am not standing for audition here or in the court to substantiate the discussion. Even in the court the medical facts and truths are not refuted by the judge.

I bring facts just for the benefit of coding only.

Again, let me tell you that I brought those points only to support the validity of assignment  of the code that is there , but only AFTER when you refuted it saying it is not correct and "Cervial Stump Code" is correct.

 Let us make an end to this topic here


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## btadlock1 (Dec 22, 2010)

Surely you don't honestly expect to have the last word on this issue. I can deal with the fact that the remnant cuff may not be cervical tissue - the code assignments I suggested are not going to work for this scenario with the documentation provided - I'm big enough to admit that I don't know everything. The forums provide a trivia-type learning platform for me - I don't expect to have all of the right answers every time, and I use the mistakes I make as an opportunity to learn something new. I am not an expert by any means; as far as I'm concerned, I'm still a student. Now, if we're done dwelling on the fact that I was wrong about my code assignment, maybe we can address the mistakes that you have made in _your_ advice. Let's compare what you've suggested with the original OP note, as we did with mine.

"Operative Indications: 
53 y/o gravida 3, para 3 status post vaginal hysterectomy w/colporrhaphy several years ago who reports dyspareunia point tenderness in the apex of the vagina during intercourcse. The patient has recently been treated for vaginal atrophy w/some improvemtn, although the patient reports there is still tenderness at the area and desires removal of the cuff remnant. 

Operative Technique:
Patient was brought to the OR. A time out was performed. She was prepped and draped in a normal sterile fashion in the dorsal lithotomy postion. Her legs were placed in candy cane stirrups. Initially it was through that a LEEP instrument would be good to remove the remnant; however, upon revisualization of the vaginal cuff and considering the narrowness of her vagina this was not done. Instead a 15-blade scalpel was used to excise the less than 5-mm remnant. Minimal estimated blood loss was present. Pressure was held at the area of bleeding and a small amount of Monsel was placed at the area of the excision for hemostasis. Please not that prior to the beginning of the case bimanual examination was done as well as emptying the bladder. The vaginal canal was reinspected after removal of the remnant. The mesh was palpated at the posterior aspect of evidence of room for a surgical expansion of the vaginal length or width. The case was then ended. The sponge, lap and needle counts were correct times two. Please note that also prior to the beginning of the case a bolus solution of lidocaine with epinephrine 1:100,000 was used and less than 1 ml was injected in the vaginal cuff remnant that was to be removed."

Let's start at the beginning: 
"Post Vaginal  Hysterectomy wih colporrhaphy done many years ago- that means  the Cervix is totally removed along with the body of the uterus, There is no cervical stump left behind. So it is NOT cervial tissue." Your first statement is based off of an assumption. The note does not say "Radical hysterectomy" or "trachelectomy", or even "total hysterectomy". In fact, there's no indication _*at all*_ that the cervix was *ever *removed. A colporrhaphy alone does not imply that all cervical tissue has been removed - the two are not synonymous, and one does not serve as a pre-requisite to the other. So, regardless of _any _code I've mentioned at any point in time, *your* belief that there is no cervical tissue whatsoever is based off of a conclusion that *you* jumped to; there is no factual basis in the records provided. Everything you suggest is contaminated by this initial fabrication.  

Assumption #2:
"Colporraphy done with a Mesh left.  So the tissues could be the redundant portion tag of the vaginal tissues (which could happen while the process of healing of the approximated site of vaginal incisional margins) or a new growth of tissue. there is no possibility of any other tissue jutting out there to merit its presence." Colporrhaphy done with mesh left? How do you know that? Did you see it? It certainly wasn't documented. You then proceed to provide more conjecture about the situation with no support in the context of the medical record. Take note of the phrases I've underlined. "Could" = "I'm guessing". Once you finished re-creating this patient's surgical history in the image you dreamed up, you reinforce your correct-ness by referencing the flawed "facts" you bestowed on this case in the first case, with the claim that there is no possibility the tissue could be anything other than what you say.

Your advice:
"As such I would give 57135 excision of tumor/cyst or any vaginal core or mass of tissues , until and otherwise the pathology report comes different." There are _several_ things wrong with this statement. First, there is no mention whatsoever of any cyst or tumor in the note. Zip. Zilch. Nada. Go ahead - check it again. It's not there. There's also no indication at all that there would _ever _be a pathology report, or that the physician even had the slightest suspicion of a pathological connection to the problem. Take note of the *absence *of words like "sampling", "biopsy", "malignancy", and any other term that might point to a disease or illness. The record isn't even clear as to the reason for the initial hysterectomy. There's not enough history or description provided to point to any specific code assignment - the note is just too vague. 
Also, the phrase "or any vaginal core or mass of tissues" is *NOT *part of 57135's code description. You don't have the authority to re-write the CPT manual for your convenience, so don't add things that aren't there.

You often tout your expertise and cite your decades of experience (although this is the first time you've also mentioned your medical degree). I'll be frank; you've given bad advice here. By "bad advice", I don't mean that you've given an answer that is incorrect, per se. I mean that you are advocating the complete fabrication of details that have a significant impact on code selection, and ignoring the most basic principles of ethical and correct coding, because you're certain that you're right. I hate to be the bearer of bad news, but that's about as wrong as one can get. I don't care if you've had 5 days of coding experience, or 50 years. You could have _literally _written the book on the subject; *it doesn't matter*. Medicine is not black and white, with cookie-cutter scenarios that follow the same prescribed course for every person, every time. It is not okay to utilize conjecture to apply specificity to a situation, in the complete absence of supporting evidence. *You do not code based on information that doesn't exist in the medical record. Ever.* It can and will be construed as fraudlent billing practices, for good reason. It is not our place to fill in the blanks to supplement insufficient documentation. The physician in this case should be asked to provide clarification, by appending the official record. Otherwise, an accurate and specific code assignment will not be possible.

Ordinarily I prefer to let disagreements go once I understand the conflict, and I try not to come across as condescending, but at the present moment, I'm not doing a very good job of either. I have to draw the line somewhere, and although I can usually put up with your apparent superiority-complex (during the frequent occasions I've encountered it), I will not tolerate being treated like an imbecile by anyone, particularly when they are so cavalier about rationalizing their answers using non-existent "facts". You really don't have to take every slight critique of your answers as a personal insult. It's ridiculous, and it makes you seem petty; it's certainly not earning you any credibility. Drawing plausible, alternative conclusions regarding the code selection in some cases is not only possible, but is essential to ensuring that every angle of the situation has been inspected by people with differing points of view. Attacking others for simply having the audacity to question your judgement, and refusing to admit that you could actually be wrong, will not make you any more correct. You are not infallible; your logic is not perfect, and your expertise does not entitle you to bend the rules, or berate others for having an opinion that contradicts yours. You don't have to win every argument, even by sheer willpower. Rather than getting all huffy when your reasoning is challenged, just accept that not everyone has had the benefit of being you, therefore they may have a different take on things. No one will condemn you for acting like you've got a little bit of humility.


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## LOVETAMBRA (Jan 9, 2013)

Ouch- you go brandi


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