Ob-Gyn Coding Alert

Question: A pathology report comes back with a weight of 309 grams. The specimen included the uterus, tubes, ovaries, and cervix. Should I use that weight as the total? Should I report 58571 or 58573?

Pennsylvania Subscriber

Answer: The weight in 58571 (Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube[s] and/or ovary[s]) and 58573 (Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube[s] and/or ovary[s]) refers to the uterus (or minus the cervix if the ob-gyn performed a supracervical hysterectomy instead).

The weight does not include the tubes and ovaries. Although these parts do not usually weigh much (unless the patient had nodules and cysts), their presence in the specimen will not usually mean you have to code a uterus less than 250 grams if you are more than 50 grams above the limit.-If you are already close to that weight, however, go to the lower one.-

Action: You might want to inform the lab that aggregate weight has an impact on billing.-But if the physician has removed the entire system en bloc, you can go only with the aggregate.