# Surgeon wants to bill LTH and Excision Broad Ligament Fibroid



## dcrossman (Nov 15, 2012)

Hello All-

My doc wants to bill out a Laparoscopic Total Hysterectomy (daVinci Robot Assist) and also an Excision of Broad Ligament Fibroid. I'm not sure how to code this, or if I CAN code the 2 procedures.  I'm not sure that I should.  The broad ligament (if I'm correct, which I may NOT be) is part of what supports the uterus.  So I'm not sure if removing the fibroid would be inclusive or not.  I have NO IDEA how to code this, other than the Lap. Total Hyst code of 58570.  Can anyone help clarify this for me?


The note says...

POSTOPERATIVE DIAGNOSES:
1. Pelvic Pain
2. Fibroid Uterus
3. Right ligament fibroid.

PROCEDURE: Laparoscopic total hysterectomy and removal of right broad ligament fibroid, da Vinci robot assisted.

FINDINGS: The uterus was grossly enlarged and boggy consistent with fibroids or with adenomyosis  The ovaries were grossly normal bilaterally, as were the tubes.  Evidence of follicle release on the left ovary.  There was a mass in the right broad ligament, which was visible and palpable.  Dissection revealed a 3 cm diameter mass consistent with a fibroid, possibly degenrating.

PROCEDURE IN DETAIL:  After general anesthesia was obtained, the patient was placed in the low gynecologic stirrups and the abdomen and vagina prepped and draped in the usual sterile fashion.  A vaginal cuff ring identifier was placed, and a probe was placed in the uterus for intraoperative manipulation.  A Foley catheter was placed.  The supraumbilical area was infiltrated with a local anesthetic with epinephrine, and a sharp incision was created.  The abdomen was manually elevated, and a 12 mm blunt trocar was inserted into the abdominal cavity without difficulty.  The laparoscope was placed, and visualization of the abdominal contents revealed no evidence of injury.  Evaluation of the pevic organs revealed the findings as detailed above.  Then, 8 mm trocars were placed bilaterally, and a 5 mm irrigating port was placed in the left midclabicular line.  The da Vinci robot was advanced and docked.

The surgeon retired to the console.  The bipolar device was used to cauterize the cornual attachments of the adnexal structures to the uterus.  They were divided.  The round ligament was similarly treated.  Dissection was continued inferiorly to the level of the mass and the uterine vessels.  Dissection was continued anteriorly along the bladder reflection.  The idential process was completed on the left side.  The mass on the right side was dissected laterally.  The right-sided were cauterized and divided.  The left-sided uterine vessels were also isolated, cauterized and divided.  The bladder was sharply and bluntly reflected from the anterior surface of the vaginal cuff.  Attention was then directed to the right-sided broad ligament mass.  This was dissedcted out of the broad ligament with blunt and sharp dissection.  It was place in the cul-de-sac for later retrieval.  Bipolar cautery was used to incise the vaginal cuff.  The uterus and cervix were removed en bloc and submitted for pathologic analysis.  The vaginal cuff was then closed with a V-Loc suture.  The pelvis was then irrigated and hemostatis verified.  This was re-verified under released abdominal pressure.  Both ureters were noted to be peristalsing normally.  The robotic portion of the case was then terminated, and the surgeon scrubbed in abdominally.  Postoperative photographs were taken.  The 12 mm incision was closed at the fascial layer with a 0 Vicryl interrupted.  Each incision was closed at the skin layer with 4-0 Monocryl subcuticulary applied.  Sterile dressings were applied, Foley catheter removed and the vaginal cuff inspected and hemostasis verified.  The patient was the returned tot he supin position, where she was awakened and taken to the recovery room in a stable and responsibe condition having tolerated the procedure well.


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## kvangoor (Nov 15, 2012)

I agree with you. Severing or excision of the broad ligament is included in the hysterectomy code. I would use only the 58570 as well.


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