Ob-Gyn Coding Alert

Question: What procedure codes should I report for this note?

"On 12/20/12, the patient was brought to the operating room and under general anesthesia the abdomen was prepped and draped. The Foley placed in the bladder was noted to drain clear urine. The suprapubic transverse incision was made and it was deepened to the fascia that was divided and separated from the underlying peritoneum that was entered. The peritoneum was digitally stretched and the fundal myoma was easily delivered through the wound. Vasopressin 10 units in 50 ml was injected, 10 ml in the anterior capsule, 10 ml in the posterior capsule and 5 ml on each side. The Bovie was used to coagulate the bleeders on the surface of the fibroid. The Bovie tip was used to divide the capsule and the Ligasure was used to separate the myoma from the underlying myometrium. The large bleeders were suture ligated. The myoma was sent for pathology. The fundal reconstruction was done in 4 layers using 3-0 Vicryl interlocking suture followed by running second suture and submucosal third suture and the fourth 3-0 Vicryl suture was used for approximating the serosa. The instruments, needles, sponges, and lap packs count was correct. The blood loss was 150 ml. The abdominal wall was closed in layers using 3-1 Vicryl for the peritoneum, #1 Vicryl for the fascia and 3-0 Vicryl subcuticular suture for the skin. Marcaine 0.5% was injected into the wound. The patient tolerated the procedure well and was transferred to recovery room in stable condition."

Kentucky Subscriber

Answer: This is an abdominal approach myomectomy which you should code based on the size of fibroid: 58140 (Myomectomy, excision of fibroid tumor[s] of uterus, 1 to 4 intramural myoma[s] with total weight of 250 g or less and/or removal of surface myomas; abdominal approach) if the total weight of the single fibroid was 250 g or less, or 58146 (Myomectomy, excision of fibroid tumor(s) of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g, abdominal approach) if over 250 g.  Since this was only one fibroid, you should look to the pathology report for the weight of the fibroid to support the code selected.

Note, however, you can only report 58146 for intramural myomas. You should use 58140 no matter how many surface myomas were removed (i.e., fibroids that did not need to be excised from the uterine muscle). This appears to be an intramural fibroid.