# 58548 Vs 58571 and 38572



## dmaguire

Good Morning,
I am currently working with a practice in which I had audited and surgery in which they would bill 58571 (Laparocsopy, surgical, with total hysterectomy, for uterus 250 g or less with removal of tube(s) and/or ovary(s)) and 38572 (Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy) single, or multiple with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple).  I felt that the appropriate code should have been 58548 (Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube (s) and ovary(s), if performed. My feeling was billing with their codes were unbundling.  They disagreed because the hysterectomy they said was not radical. I am trying to understand the difference because when I read the op note to me it seemed to cover how I would have billed.  This is not my area of expertise for those of you who code this every day I would appreciate any guidance you may offer. The op note is below.

PREOPERATIVE DIAGNOSIS: Endometrial cancer.

POSTOPERATIVE DIAGNOSIS: Endometrial cancer.

OPERATION PERFORMED: Robot assisted total laparoscopic hysterectomy with bilateral salpingo-oophorectomy, pelvic and paraaortic lymphadenectomy.

FINDINGS:  The uterus is top normal in size.  The ovaries and tubes are grossly normal. There is no gross evidence of adenopathy.  There is no peritoneal ascites.

DESCRIPTION OF SURGERY:  After the patient was identified and a preoperative time out was observed, the abdomen, vulva, perineum and vagina were prepped and draped in the usual fashion for surgery.  A Foley catheter was placed into the bladder and a VCare apparatus was placed into the endometrial cavity with the cup tightly affixed to the cervix.  After changing gloves, an incision was made at the left costal margin at the midclavicular line.  A 5 mm port was placed into the peritoneal cavity using a 5 camera.  CO2 was insufflated into the peritoneal cavity and a 12 mm port was placed in the midline 10 cm above the umbilicus under direct visualization.  Accessory 8 mm ports were then placed at 10 cm intervals on either side of the central incision and slightly superior.   An additional 8 mm port was placed laterally on the right.  The robotic device was then docked.

With monopolar scissors on the #1 port and a bipolar Maryland on the #2 port, the pelvic sidewalls were entered and the ureters were identified.  A window was created between the ureter and the infundibulopelvic ligament (IP) and the IP ligament was coagulated with bipolar energy and divided.  This was done bilaterally.  The round ligaments were then coagulated and divided at the midpoint of the ligament.  The broad ligament leaves were then divided and the bladder flap was created.  The uterosacral ligaments were then coagulated and divided and the uterine vessels were coagulated and divided on either side.  A colpotomy incision was then made over the VCare cup and the uterus, tubes and ovaries were delivered through the vagina.

A radical pelvic lymphadenectomy was then performed bilaterally, removing all lymph bearing tissue in the region defined by the midportion of the common iliac artery, the lateral and medial circumflex iliac veins, the pubic ramus, the obturator nerves and the genitofemoral nerves.  The iliac vessels were skeletonized. The specimens were removed transvaginally with the use of
5 mm bags.

The visceral peritoneum overlying the right common iliac artery proximal to the ureter was divided, continuing the dissection over the aorta to a point above the inferior mesenteric artery.  The fat pad overlying the inferior vena cava was mobilized from the vessel and the aorta while the ureter was retracted laterally.  Perforators were coagulated with bipolar energy.  The specimen was labeled appropriately and removed transvaginally in a 5 mm Endobag.  With the inferior mesenteric artery retracted anteriorly, the left side of the distal aorta was approached and the psoas muscle on that side was identified with the ureter and gonadal vessels retracted laterally.  The lymphatic bundle demarcated by the proximal left common iliac artery, medial margin of the psoas muscle, left margin of the aorta and the inferior mesenteric artery was then mobilized and removed, coagulating margins with bipolar energy.  The specimen was labeled appropriately and removed through the vagina in a 5 mm bag.

The vagina was then closed with a running 2-0 Glycomer 90 V-Loc suture.  The uterosacral ligament remnants were imbricated with 0 Vicryl.  The pelvis was thoroughly lavaged and no evidence of bleeding was noted.  All instruments were then removed.  Sponge count was correct x3.  The robotic device was undocked and CO2 was permitted to exit the abdomen.  After the ports were removed, the fascia for the camera port was approximated with 0 Vicryl using an Endoclose device.  All skin incisions were closed with 4-0 Vicryl.  The patient was then sent to the recovery room in satisfactory condition after the vagina was examined and found to have no injury and no evidence of bleeding.  The cuff closure was adequate.  All instrument and needle counts were correct.


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## karey

A "radical" hysterectomy is when they excise part of the vagina or take a vaginal margin along w/ the hysterectomy portion. In most cases the 58571 and 38572 is correct and it is not considered unbundling. 58571 is removal of the uterus and BSO. 58548 is removal of the uterus, portion of the vagina and BSO. (and of course the lymph nodes)

The below surgery is not a Radical hysterectomy.


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## dmaguire

Thank you Karey, I have been working very closely with the providers and I want to make sure we are doing the correct thing.  Not being clincial can have its challenges.  

Danielle


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## karey

Give me your e-mail and I can send you some information that breaks it all down for you


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## dmaguire

my email is dmaguire@pinnaclehealth.org.  Thank you I appreciate any additional information you can offer me.


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## Practice Coder I

*58548 vs. unbundled*

Hello,

I do agreed with the auditor, 58548 can only be used if the op notes specifically mentions as radical hysterectomy, with BSO, and P/A.
If it does not mention it anywhere in the op notes, then you cannot use 58548 at all. You can use 58552 for RALTH,BSO and 38572 for P/A.

Looking at your Op Notes, there's nowhere in this dictation that everything is done Laparoscopically to be coded as 58571. It seems to me like as mentioned it is done Robotically through vaginal approach. 

Keep in mind 58571 is done laparoscopically with either detached from the abdomen or vaginal, with the vaginal cuff being closed laparoscopically. As  58552 is done with vaginally approach with detached vaginally with the vaginal cuff being closed vaginal approach.

58571--done through the scope
58552--done vaginal approach

I have been coding for Gynecology Oncology for almost 6 years. And believe me, i code these almost everyday.

Hope this helps.


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## jlgwalt64

*58552 vs 58571*

Practice Coder I,

While you are correct in stating that 58552 is a laparoscopy with a total vaginal hysterectomy and 58571 is a total laparoscopic hysterectomy, your statements are incorrect. You stated there was nowhere stated that the procedure was a 'total laparoscopic' procedure but the surgeon does mention this in the title - "Robot assist Total laparoscopic hysterectomy..." but it's also defined in the operative report by the procedure he performs. He performs a totally laparoscopic hysterectomy. He only uses the vagina to extract specimens from the pelvic cavity, this is very common. Nowhere in this report does he go down and perform any part of the hysterectomy, whereas a vaginal hysterectomy involves using instruments through the vagina to excise and extract the specimens.
The correct coding is as discussed 58571 and 38572, depending on the payer S2900 could also be coded for the robot-assist.


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## ashley.smith@nmhs.org

karey said:


> Give me your e-mail and I can send you some information that breaks it all down for you


this is 7 years late. but can you send it to my email?

ashlynn53574@gmail.com

i'd truly appreciate it so much!!!


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## domonique

ashley.smith@nmhs.org said:


> this is 7 years late. but can you send it to my email?
> 
> ashlynn53574@gmail.com
> 
> i'd truly appreciate it so much!!!


Two years later!!! @ashley.smith@nmhs.org did you receive the information? If so, can you send it to me @ domonique.perkins.dp@gmail.com


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## csperoni

This thread is so old that this is not usually how (at least by my surgeons) this surgery is currently performed.  To me, the best reference for gynecologic oncology coding is SGO (Society of Gynecologic Oncology) or ACOG (American College of Obstetrics & Gynecology). 
Here is SGO's 2021 coding and reimbursement questions and answers.  They typically update every few years, or any year there are significant changes.
Regarding the original question from 9 years ago.  It was coded correctly as 58571 and 38572, since the hysterectomy was not radical.
I do not agree with other advice that this is 58552.  All detachments were done via laparoscope.  It is not clear to me how the vaginal cuff was closed (vaginally or laparoscope), but either way, since ALL ligation/detachment was done via scope prior to the colpotomy, 58571 would be correct.  Here is a very good ACOG reference explaining the differences between laparoscopic assisted vaginal vs laparoscopic hysterectomy. PS- I would provide some documentation education to my providers about making it clearer for the approach to cuff closure.
Again, at least by my surgeons, it is rare to currently perform 38572, and are typically doing a sentinel lymph node mapping first (38900-50) and removing only the sentinel nodes 38570.  SGO's reference mentions this at the top of page 12.  Identifying the sentinel nodes and removing only those still accurately stages the cancer and is less likely to result in long term complications for the patient.


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