Ob-Gyn Coding Alert

Question: This patient had a TLH on 11/17/17 and on 11/24/17 had the surgery below. Not sure what to bill? 58999-78, 57023-72, 57200-78. If unlisted, what would I compare this to?

Note: The patient was taken to the operating room where she was placed in the supine position. After undergoing adequate general endotracheal anesthesia, she was placed in the Allen stirrups in the dorsal lithotomy position. Both arms were tucked to the side. The patient was then prepped and draped in the usual fashion and Foley catheter was placed into the bladder. Attention was first turned to the vagina where a sponge stick was gently was placed in the vagina. A 5 mm incision was made in the LUQ at palmer's point and access was gained into the abdomen using the opt iView technique. There was no evidence of bowel injury or bleeding. Pneumoperitoneum was obtained. Two accessory 5 mm ports were placed in the bilateral lower quadrants and the umbilicus as previous incision. The above findings were noted.

The cuff was obscured by dense loculations of bowel and early formation adhesions attaching bowel to bladder dome. The adhesion was inspected and with gently downward traction on the bowel the loculation and adhesion was separated and ~ 150 cc's of liquefied blood was released, the cul de sac being partial exposed was irrigated and suction and the bowel adhesion to bladder dome and cuff was gently and meticu­lously corrected using gently blunt dissection taking great care to inspect bowel and insure no serosal defects were made. The posterior cul de sac restored, attention was turned to that adnexae. Each ovary was pined to their respective side walls and were restored to a free hanging position with careful blunt dissection clearing them gently from medially attached bowel. With the pelvic anatomy restored the remaining inflammatory debris irrigate and suctioned away. The assistant went below to interrogate the cuff under laparoscopic observation and no defect was felt of noted on laparoscopy. The cuff was inspected meticulously as were all operative pedicles in a standard hysterectomy and no active bleeding was noted, just expected oozing from the lysis of adhesions in the post operative state. The bladder was also found to be without major bleeding. Attention was turned to the vagina were the bladder was backfilled with sterile water and a 30 degree 5 mm scope was inserted into the bladder and bilateral ureteral efflux of concentrated urine was noted as well as a non-traumatized bladder dome. The scope was removed, the bladder was drained and the Foley removed. The cuff was inspected vaginally and no active bleeding was seen and the cuff was found to be intact. Sterile gloves were donned and attention turned to the abdomen were again hemostasis was assured. The pelvis was irrigated with copious amounts of warmed saline and suctioned and arista was applied to the pelvis. Hemostasis was assured. The lower quadrant and upper quadrant trocars were removed under direct visualization and the pneumoperitoneum was reduced and Once the pneumo­peritoneum was completely reduced, the final trocar was removed. Skin of all incisions was closed with 3-0 Monocryl in a horizontal mattress type suture for integrity given repeat operation in the setting of incomplete healing and local was injected at all sites. Pressure dressings were applied to the skin for skin closure. All sponge, lap, needle, and instrument counts were correct times two.

What should I report?

Vermont Subscriber

Answer: Let's break this down by potential options and why they don't work.

First, you have no vaginal hematoma described here. They found blood under the adhesions that were on top of the vaginal cuff. You would use code 57023 (Incision and drainage of vaginal hematoma; non-obstetrical (eg, post-trauma, spontaneous bleeding)) only to report removal of a hematoma via the vagina but cutting into the vaginal wall.

Code 57200 (Colporrhaphy, suture of injury of vagina (nonobstetrical)) describes repair of the vaginal wall, but again, there is no description of this being done. The vaginal cuff was intact with no bleeding other than oozing.

They did, however, do laparoscopic lysis of adhesions, andthat is the code you should report. You should report 44180-78 (Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure); Return to the operating room for a related procedure during the postoperative period)) for this because it was bowel adhesions they removed.