# Diagnostic Laparoscopy with Total Vaginal Hysterectomy vs Lap, surgical, w vag hyst



## OBcoder2017 (May 18, 2016)

I am having a debate with a colleague who codes for another doctor.  My doctor will sometimes do an Assist with him and we are coding our surgeries differently for the same procedures therefore causing a problem with the insurance reimbursement and denials.  I have discussed this with my physician to confirm how he does his Total Vaginal Hysterectomy and he confirms that he uses the laparoscope diagnostically only to determine if the hysterectomy can be carried out vaginally or if he feels it would need to be an open procedure.  If he determines that it can be done vaginally, he then proceeds with the surgery and does the entire hysterectomy vaginally.  The ACOG guidelines state that in order to code for a Laparoscopy, surgical, with vaginal hysterectomy (58550) "Detachment of entire uterine cervix and body via the laparoscope and vagina" must be done.  ACOG further states, "LAVH includes laparoscopically detaching the uterine body from the surrounding upper supporting structures. The vaginal portion of the procedure is then performed."  My colleague said she was told years ago by an insurance company that she had to use the 58550 and that the diagnostic scope was bundled.  As a result of the ACOG guidelines, I have been submitting Diagnostic Laparoscopy 49320 with Total Vaginal Hysterectomy 58260.  The CCI edits do not require a 59 modifier but my Encoder Pro tips suggest that I use the 59 modifier when the Scope is not used as part of the surgical procedures. Some of the insurance companies do question this, but I send the op notes when needed and I am successful with getting this paid.   It does take more time, but there is more reimbursement since the scope is not bundled and clearly is being used as a separate procedure.  Could someone weigh in on this as to what the proper coding should be.  I don't have to be right.  I just want to do it right.  Thank you so much in advance.


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## CodingKing (May 18, 2016)

NCCI database does not have every instance of incorrect billing possible as they add things as they see trends.

Here is what NCCI has to say:



> If a laparoscopy is performed as a “scout” procedure to assess the surgical field or extent of disease, it is not separately reportable. If the findings of a diagnostic laparoscopy lead to the decision to perform an open procedure, the diagnostic laparoscopy may be separately reportable. Modifier 58 may be reported to indicate that the diagnostic laparoscopy and non-laparoscopic therapeutic procedures were staged or planned procedures. The medical record must indicate the medical necessity for the diagnostic laparoscopy.



They are correct though Diagnostic scope is bundled into a surgical scope since its impossible to do a surgical scope without first assessing the surgical field but I believe that only applies if its the same access point for both. Here is what I found in the NCCI manual about dx w/ surgical:



> All surgical laparoscopic, hysteroscopic or peritoneoscopic procedures include diagnostic procedures. Therefore, CPT code 49320 is included in CPT codes 38120, 38570-38572, 43280, 43651-43653, 44180-44227, 44970, 47562-47570, 49321-49323, 49650-49651, 54690-54692, 55550, 58545-58554, 58660-58673, and 60650. CPT code 58555 is included in CPT codes 58558-58565.


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## OBcoder2017 (May 18, 2016)

Patient was having pelvic pain and abnormal uterine bleeding prior to the procedure.  Diagnostic Scope was scheduled to determine the problem.  During the Diagnostic Scope it was found that patient had severe uterine descensus and the determination for vaginal hysterectomy was made.  The plan was to do a vaginal hysterectomy if possible, however, prior to the surgery. 

Thank you for the CCI excerpt.  I do not see 58260, 58262 in those codes that include the scope.  Since 58260 and 58262 are vaginal hysterectomy and not open, it would seem that the scope might be able to be billed separately even though the scope did not result in an open procedure.  Is my thinking going in the right direction here?


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## CodingKing (May 18, 2016)

The additional information you provided helped. Different approaches and scope was decision for surgery so i think you are right.


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## OBcoder2017 (May 19, 2016)

Would you agree that using the 58550 (Laparoscopy, surgical with vaginal hysterectomy) would be inappropriate since the physician does not do any part of the surgical removal or procedure with the scope?


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