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Ob-Gyn Coding Alert

Reader Questions:

Rely on Documentation for Modifier -22

Published on Thu Apr 28, 2005

Question: My doctor's note said that she did a total abdominal hysterectomy (TAH) with a "huge uterus" greater than 1 kg. I see codes designating different uterus sizes for a total vaginal hysterectomy (TVH) but not a TAH. Should I report modifier -22 to reflect this?

Washington Subscriber Answer: The uterine size doesn't necessarily make a difference, and that is why you won't find a code for TAH based on size. The incision gives the ob-gyn good access to remove it.
 
If your documentation shows difficulty in removing the uterus because the doctor couldn't locate the ligaments and the surgery took much longer than expected (and this was described well in the op report), you may have a case for applying modifier -22 (Unusual procedural services) to 58150 (Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]).  - The answers for Reader Questions and You Be the Coder were provided by Melanie Witt, RN, CPC, MA, an ob-gyn coding expert based in Fredericksburg, Va.
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