# Vaginal Hysterectomy, Anterior Colporrhaphy



## mslori7

Hi,

Can someone help me out on this procedure.  The patient had a Vaginal Hysterectomy (uterus), Anterior Coloporrhaphy, Repair of Cystotomy and Cystoscopy.  It was coded as 

58260
57240
52000
51535

Are these the correct codes to use for this case?

Thanks,


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## preserene

Could you please send the op notes  and the preop. diagnosis so that i could get to the correct coding.
If not , then with the info and with the inherent nature of the scenario, i could suggest some thing : 
The vaginal hysterectomy is the major/main procedure. The very structure of the procedure itself includes the anterior colporrhaphy; *so there is no need for reporting anterior colporrhaphy code separately*

Was there a  preexisting vesical fistula associated or wound created at the time of surgery?
 Or was Cystotomy made for some purpose or what ?
It looks like the cystotomy was made that time of the procedure and consequently a repair was done ; then it would go for 51860, or 51865.

And if the cystoscopy was done for diagnostic alone, well you could report it separately.
All these are reasonable procedures by a OBGYN

The code 51535  is for cystotomy done for incision/excision or repair of ureterocele ( mind it was not for urethrocele). I am not sure why the ureterocele repair was done by cystotomy ; THIS REPAIR OF URETEROCELE will be done necessarily by urologist and not by OBGYN. Was there an urologist as co surgeon?

So this is the suggested ones. If I could get to the procedure and diagnosis then we could  refine/redefine well


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## mslori7

Hi,

Can you send me your email address and I'll send the op report to you.

thanks,


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## mslori7

Hi,

Can you send me your email address and I'll send the op report to you.

Thanks,


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## mslori7

*Operative Report*

PREOPERATIVE DIAGNOSIS:  Stage 2 uterovaginal prolapse.

POSTOPERATIVE DIAGNOSIS:  Stage 2 uterovaginal prolapse.

OPERATION:  VAGINAL HYSTERECTOMY, ANTERIOR COLPORRHAPHY, REPAIR OF
CYSTOTOMY, AND CYSTOSCOPY.

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  100 cc.

FLUIDS:  2 liters crystalloid.

URINE OUTPUT:  200 cc clear urine at the beginning of the procedure.

FINDINGS:  Small anteverted uterus with stage 2 prolapse, as well as grade 2 cystocele.

COMPLICATIONS:  A 2-cm cystotomy which was repaired in 3 layers and was recognized immediately.

INDICATIONS:  The patient is a 58-year-old G1, P1-0-0-1 who presented to her gynecologist with a  uterovaginal prolapse.  She desired to pursue a surgical plan for her prolapse and was counseled to undergo LAVH or possible vaginal hysterectomy.  After informed consent was obtained and risks of the surgery were reviewed with the patient, she was taken to the operating room.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed in the dorsal lithotomy position prior to induction of anesthesia due to her bilateral hip replacement.  After she felt comfortable and the position was confirmed, the general anesthesia was induced without difficulty.  After that, a vaginal exam was performed and a
stage 2 prolapse was confirmed.   At this point, the decision was made to start with a vaginal hysterectomy given the small size of the uterus and, if necessary, proceed with laparoscopy during the case.  She was prepped and draped in the usual sterile fashion for both a vaginal hysterectomy, as well as for possible laparoscopy.  The bladder was drained with a straight catheter with 200 cc of clear urine.  A weighted speculum was placed in the vagina.  The cervix was injected circumferentially and an incision was made
in the cervix circumferentially.  The posterior peritoneum was entered with sharp and blunt dissection without any difficulties.  The posterior peritoneum was attached to the posterior vagina at the 6 o'clock, 4 o'clock, and 8 o'clock with 0 Vicryl suture in an interrupted fashion.  The uterosacral ligaments were clamped, cut, and tied bilaterally with 0 Vicryl suture.  At this point, the attempt was made to push the bladder off the
anterior portion of the uterus and to enter the cul-de-sac.  A clean plane was felt between the uterus and the bladder and entry was attempted.  As soon as the cut was made, clear urine started to leak out from the bladder and a cystotomy was obvious on physical exam and was confirmed with passing a straight catheter through the urethra.  The cystotomy was not larger than 2 cm and the decision was made to repair this.  The cystotomy was repaired with 2-0 and 3-0 running stitches in 2 layers and appeared to be watertight.  Cystoscopy was performed at this point after Indigo Carmine was administered and good distension was noted with no leakage of the cystotomy, as well as good bilateral ureteral jets.  At this point, the decision was made to continue with the vaginal hysterectomy.  Metzenbaum scissors were then used to cut further and deeper down at the cervix and
the bladder was pushed further up higher.  Finely, I was able to get to the anterior peritoneum as a finger was passed on the lateral side from posteriorly to identify the anterior cul-de-sac.  After anterior entry was made, a right-angle retractor was then placed.  The cardinal ligaments, the broad ligament, and the utero-ovarian ligaments were serially clamped, cut, and tied with 0 Vicryl suture.  Ovaries were inspected and found to be normal.  The decision was made not to take them out as it was too high up to be able to see if they could be safely reached.   The uterus was then removed and sent to Pathology.  The decision was made to proceed with the anterior colporrhaphy.  Pitressin was injected after 2 Allis clamps were used to tent up the redundant anterior vaginal mucosa.  The incision was made with the scalpel.  The anterior vaginal wall and the pelvic fascia was released from the vaginal fascia using Metzenbaum scissors and sharp
dissection.  The endopelvic fascia was reapproximated in the midline using interrupted 2-0 Vicryl horizontal mattress stitches.  The excess vagina was then removed and the incision was reapproximated in the midline using 2-0 Vicryl running stitches.  After that, the pedicles were inspected again and there was no further bleeding noted.  A Mayo needle was used to pass the 0 Vicryl suture from the uterosacral ligament through the posterior portion of the vagina.  After that, the vaginal mucosa was reapproximated in a horizontal fashion using 2-0 Vicryl suture.  The uterosacral ligaments at the end were tied together on both sides to suspend the vaginal wall.  Good hemostasis was noted.  A Foley was inserted and there was minimal urine return.  The decision was made to repeat the cystoscopy.  Cystoscopy was repeated and good distension was again noted with good bilateral jets and there was no visible injury to the bladder.  Thus, a Foley catheter was
inserted and the return of fluid was confirmed at this point.  The vagina was packed and there was no bleeding or leakage of the cystostomy noted at the anterior vaginal wall.  The patient was then reversed from her general anesthesia and was taken to the recovery room in stable condition.


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## preserene

Yes perfect . Now, the procedures undertaken are Vaginal Hysterectomy. Where in the anterior colpo is an integral part.
The second mandatory procedure is Cystotomy Repair which is a separate distinctly identifiable procedure to which you can append Mod 59 .
Then the diagnostic cystoscopy which is not related to the main procedural course of cystotomy Repair. So you would code it separately as a diagnostic, only once.
You could append to the primary procedure  Mod 22, because it involved with more work and time consuming with increased work than usual


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## mslori7

Thank you so much, so I have 58260 (22), 51860 (59) and 52000


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## acf7575

*New to GYN - Bundling update info requested re:  52000 billed with 51860 and 58260*



preserene said:


> Yes perfect . Now, the procedures undertaken are Vaginal Hysterectomy. Where in the anterior colpo is an integral part.
> The second mandatory procedure is Cystotomy Repair which is a separate distinctly identifiable procedure to which you can append Mod 59 .
> Then the diagnostic cystoscopy which is not related to the main procedural course of cystotomy Repair. So you would code it separately as a diagnostic, only once.
> You could append to the primary procedure  Mod 22, because it involved with more work and time consuming with increased work than usual



I am new to GYN coding.  I know this post was from 2010.  I have a question regarding now CCI bundling edits and the billing of the 52000 for current time.  52000 is column 2 edit of both codes 51860 and 58260.  52000 has been a CCI bundle with code 51860 since 10/01/2016.  52000 has been a CCI bundle with code 58260 since 01/01/2015.  It would appear this 52000 is a confirmation of repair "diagnostic" study.  Do you still recommend billing this?  I wouldn't think in this type of case the 52000 would be billable since it is an NCCI bundle.  What X modifier would you use v/s 59, XU unusual circumstances?  Please explain to me how it is separate if you would still bill it with an unbundle modifier.  

Thanks,
New to GYN -


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