Ob-Gyn Coding Alert

Warning: You should not count fibroid weight with the weight of the uterus.

Approximately 600,000 hysterectomies are performed annually in the United States, meaning that you will likely see a hysterectomy claim land on your desk. Before you feel overwhelmed by your various choices for hysterectomy procedures, isolate these four factors of the procedure:

• Approach
• Size/weight
• Extent of uterus removed
• Additional procedures performed

Factor 1: Address Your Ob-gyn’s Approach

First, you need to decide what approach your ob-gyn used. This will help you narrow down the code series you’ll work with.

Open procedures: For a hysterectomy performed via the abdominal approach, you should look to 58150-58240 or 58951-58956 if the hysterectomy was performed because of malignancy. If your ob-gyn performed a hysterectomy using a vaginal approach, you’ll pull a code from the 58260-58294 series.

Laparoscopic procedure: For a laparoscopic-assisted vaginal hysterectomy (LAVH), you’ll use 58550-58554. If your ob-gyn performed a supracervical laparoscopic hysterectomy, you’ll report one of four codes: 58541-58544. And if your physician performed a total laparoscopic hysterectomy, look to codes 58570-58575.

Why this is so important: You’ll find a big difference between laparoscopic hysterectomies and ones performed through a laparotomy incision — hence, usually higher relative value units (RVUs) and expected reimbursement for the open procedures involving the same work, says Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.

Factor 2: Scan Report for Uterus’s Size

Next, you need to know the weight of the uterus for many of the procedures — specifically whether it was 250 grams or less or more than 250 grams. This will narrow your coding options.

If the uterus weighed 250 grams or less, you’ll use 58260-58270 for vaginal approach procedures. You’ll use 58550-58552 or 58570-58571 if your ob-gyn used a laparoscopic approach or 58541-58542 if they performed a supracervical laparoscopic hysterectomy.

On the other hand, if the uterus weighed more than 250 grams, you’ll use 58290-58294 for vaginal approach procedures. You’ll use 58553-58554 or 58572-58573 if the procedure was laparoscopic or 58543-58544 if the procedure was a supracervical laparoscopic hysterectomy.

Why this is so important: Without knowing the weight of the uterus, you could be leaving money on the table. You need to be certain that your pathology report includes that. Work hard with your pathology department to make certain the weight is always there, Witt advises.

Caution: The presence of fibroids will normally increase the weight of the uterus when they are internal or lie within the uterine walls. If fibroids are removed as a separate specimen, their weight should not be combined with the weight of the uterus to determine which code to report for the hysterectomy, Witt adds.

Factor 3: Ensure Your Codes Capture the Hysterectomy’s Extent

An open or laparoscopic hysterectomy may have included more than simply removing the uterus.

The hysterectomy may be total, but you may also see a subtotal open hysterectomy, which you would code using 58180 (Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s)). This procedure involves removing the uterus (fundus) but leaving the cervix by transecting the uterus slightly below the internal os. In other words, your ob-gyn removes the uterus without taking the cervix.

Factor 4: Stop and Think Before Coding Additional Procedures

Watch out: You cannot code the removal of the tubes and/or ovaries separately when the code description states, “with or without removal of tubes and ovaries.”