# 58552 vs 58571



## lscott (Nov 27, 2018)

Can someone please clarify the difference between these two codes?  The descriptions are the uterus delivered through the vagina vs morcellization and removal.  For the following scenario I code 58552 or 58554 but the facility uses 58571.  It is definitely laparoscopic.

IP ligaments were clamped, cauterized, and transected using the vessel sealer.  This was extended thru the mesosalpinx and mesoovarium.  Next, the round ligaments were sequentially clamped, cauterized, and transected, again using the vessel sealer.  This was carried down through the broad ligament to the level of the bladder reflection, the avascular plane of the bladder flap was developed, deflecting the bladder inferiorly out of harm's way.  The uterine arteries were clamped with the bipolar cautery and cauterized. These were cut using monopolar scissors.  Next using monopolar cautery, the posterior cul-de-sac was entered over the uterine manipulating device.  The uterosacral ligaments and the cardinal ligaments were then sequentially clamped, cauterized, and transected.  The specimen was detached from the cervicovaginal junction and was delivered into the vagina.  The pelvis was irrigated. ..........

I always look for "delivered into vagina" versus being morcellized and delivered from the abdomen.  

Thanks!


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## csperoni (Nov 27, 2018)

I was instructed that the difference between 58550-58554 (laparoscopic vaginal hysterectomy) and 58570-58573 (laparoscopic total hysterectomy) is* the approach for the surgical portion, not simply how the specimen was removed*.  
A few years back (for benign cases), the physician would use a morcellator to slice up the uterus or large fibroids in order to remove it.  It allowed a patient with an enlarged/globular/fibroid uterus to have a laparoscopic hysterectomy when laparoscopic was still new and before the daVinci was everywhere.  However, there were instances where everything pointed to a benign case for fibroids, but then final pathology came back with a sarcoma or other malignancy.  As a result, the physician was taking a localized cancer and possibly disseminating it throughout the pelvis.  There are definitely lawsuits pending.  Anyway, no one uses a morcellator any longer.  I don't even think the hospital would permit it and there was an FDA warning issued in 2014.  It is standard for a total laparoscopic hysterectomy (58570-58573) to have the specimen removed through the vagina.      
The difference in coding is whether the surgery itself was done through the ports with robotic or other laparoscopic tools or whether the bulk of the surgery was done through the vagina (with an incision through the vagina into the cul de sac), with the laparoscope used to provide visualization rather than surgical access. In my area, all the physicians are doing the surgery (including the vaginal cuff closure after removing the uterus/cervix) laparoscopic and simply removing the specimen through the vagina.  The last time I needed to use 58550-58554 was probably before the 58570-58573 codes existed.    
Assuming all the ligament clamping/cauterizing/transecting were done through the laparoscopic ports, this is 58571.


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## csperoni (Nov 27, 2018)

Here is a great link from ACOG regarding this:
https://www.acog.org/About-ACOG/ACO...pic-Hysterectomy-Procedures?IsMobileSet=false


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## lscott (Nov 28, 2018)

Thanks Christine, I did read this yesterday, and I think my stumbling-block is that I'm just overthinking it, but I really want to understand the differences. In all 3 of the cases that I'm thinking that because the posterior cul-de-sac was entered to detach the uterosacral and cardinal ligaments that this makes it an LAVH.


"Then the posterior cul-de-sac was
entered over the uterine manipulating device. The uterosacral ligaments and the
cardinal ligaments were then sequentially clamped, cauterized, and transected.[/B]
The specimen was detached from the cervicovaginal junction and was delivered
into the vagina. The pelvis was copiously irrigated. The irrigant was
suctioned away. Inspection revealed excellent hemostasis at all pedicle sites and the cuff was then closed in a running interlocking fashion in 2 layers
using 0 Vicryl suture. Excellent hemostasis was again assured. All instruments
were removed from the abdomen. The gas was allowed to escape."


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## csperoni (Dec 4, 2018)

I would confirm with the provider on this, but if they are in fact doing a colpotomy and then part of the procedure through the vagina, this would indeed be LAVH. None of my providers ever perform their procedures this way (even when not using the daVinci).  They detach the entire uterus via the laparoscope - all ligaments, and then perform the colpotomy just to remove the uterus.  The vaginal cuff is also closed via laparoscopic instruments and not the vagina.      
I do want to emphasize to not just look for "delivered into vagina" or morcellation.  
Often times the coding verbiage is not the real world physician verbiage.  It's OK to check with your provider since coders (at least certainly not me ) never went to medical school.  I would rather ask for clarification than find out 2 years later I was making an incorrect assumption.  I have on occasion also asked providers (especially newbies) to slightly adjust their wording to make things clearer moving forward.


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## Cmama12 (Dec 31, 2018)

It can be confusing for sure.  In your example above, it sounds to me like a TLH as they are cutting over the KOH cup from above.

 After clarification with our providers this is what we use to help determine:

TLH: all structures and ligaments are detached with the scope. The uterus is then removed either through the port or the vagina and sewn laparoscopically (*or vaginally if that is the physician preference)*
*
LAVH: most structures are detached with the scope, then they move to the vaginal side to complete the detachment of ligaments, etc, then the uterus is removed vaginally and sewn vaginally.


Here is a note I saved as a good example of an LAVH

DESCRIPTION OF THE PROCEDURE:
The patient was taken to the operating room where she was placed under general anesthesia. She was then prepped and draped in the usual sterile fashion in the dorsal lithotomy position. The bladder was drained at the start of the procedure. Sterile speculum inserted without difficulty. A sponge stick was placed due to cervical stenosis.  

Attention was then turned to the abdomen where a 1 cm infraumbilical skin incision was made with the scalpel. A Veress needle was used to enter the peritoneal cavity. Entry was confirmed with saline drop test. The abdomen was then insufflated with CO2 gas. A 5 mm trocar was then placed at the umbilical port. Entry into the peritoneal cavity was confirmed with the laparoscope, 2 lower quadrant ports were placed under direct visualization in the left and right lower quadrants after the ligasure was used to take down adhesions in the right lower quadrant to allow port placement.  These were both 5 mm ports. The bowel was removed from the cul-de-sac. Uterus, ovaries and tubes were identified.  Using the LigaSure cautery device, the infundibulopelvic ligaments were cross-clamped and transected. The round ligaments cross-clamped and transected. The uterine vasculature was serially cross-clamped with the LigaSure device down to the level of the uterine arteries. The camera and laparoscopic instruments were removed.

 Attention was then turned to the vaginal canal. A weighted speculum was placed and the cervix was grasped with 2 single-tooth tenaculums.  The cervical vaginal junction was injected with diluted Vasopressin. A scalpel was used to circumferentially incise the cervix. The cervical vaginal tissue was dissected with Metzenbaum scissors. The anterior cul-de-sac was entered sharply. A right angle retractor was placed to elevate the bladder. The posterior cul-de-sac was entered sharply with Mayo scissors. A long weighted speculum was placed in the posterior cul-de-sac. A Heaney clamp was then used to clamp the uterosacral ligaments bilaterally, transected with Mayo scissors and suture ligated with 0 Vicryl.  The cardinal ligaments were than clamped, cut and suture ligated with 0 Vicryl.  The remaining attachments were then serially clamped, cut and suture ligated with 0 Vicryl. The uterus was delivered through the vaginal incision. All pedicles were hemostatic.


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