Ob-Gyn Coding Alert

Question: A patient previously had a hysterectomy where the physician removed her cervix. The ultrasound now shows a 10-cm pelvic mass. Our ob-gyn removed a 366 gram fibroid and the uterus. He also did a salpingooophorectomy for ovarian cysts. What code should I report for removal of the uterus?

Colorado Subscriber

Answer: You need to check the details of her previous surgery before you proceed with coding the procedure. For one, the term "hysterectomy" means removal of the uterus -- not the cervix.

Fallback: More likely, the physician of her previous procedure did a trachelectomy (57530, Trachelectomy [cervicectomy], amputation of cervix [separate procedure]).In that case, you should treat this hysterectomy as a supracervical one, meaning no removal of the cervix.

You should report 58180 (Supracervical abdominal hysterectomy [subtotal hysterectomy], with or without removal of tube[s], with or without removal of ovary[s]). Notice that this code includes removal of the tubes and ovaries.