Ob-Gyn Coding Alert

Question: My ob-gyn documented a "laparoscopic- assisted myomectomy" and I'm unsure which CPT code I should use. Is this an unlisted procedure?


New Jersey Subscriber

Answer: You should use the laparoscopic myomectomy codes 58545 (Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 grams or less and/or removal of surface myomas) or 58546 (... 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams).

These codes represent the laparoscopic alternative to the open procedures shown in 58140-58146. Because CPT distinguishes between these laparoscopic codes by the number of fibroids and their weight, these will be key components of the ob-gyn's documentation.

Example: A 34-year-old patient who recently married and is anxious to have children complains to her ob-gyn of heavy menstruation that is causing her to feel fatigued. After examining the patient, the doctor finds a 13-cm uterus with four fibroid tumors. He performs a laparoscopic myomectomy to remove the myomas.
 
Here, you would report 58545 if the total weight of the four myomas is less than or equal to 250 grams. Diagnostically, you would want to wait for the pathology report to ensure that you link the correct diagnosis code to the procedure.

If you code prior to knowing the type of myoma, the only code you can report is 218.9 (Unspecified leiomyoma of uterus). For some payers, an unspecified code after surgery may lead to a claim denial.