Ob-Gyn Coding Alert

Question: Physician removed Flishie clips at the same time as a Myomectomy. What CPT® code should you report for the clips removal? Here is the op note:

Kentucky Subscriber

Procedure(s):DAVINCI-ASSISTED LAPAROSCOPIC MYOMECTOMY AND REMOVAL OF FILSHIE CLIPS

Procedure Details:  The patient was taken to the operating room and placed in the supine position. She underwent a smooth induction of general anesthesia. She was then placed in lithotomy position and prepped and draped in the usual fashion. A timeout was taken to confirm correct patient identification and surgical procedure. Preop exam under anesthesia confirmed the uterus to be about 14 wks size, bulky and irregular.

A speculum was placed in the posterior vagina. Anterior lip of cervix was grasped with a tenaculum. A HUMI uterine manipulator was inserted.

A sub umbilical incision was made 20 cm above the uterine fundus. A Veress needle was introduced and intraabdominal placement was confirmed with the saline drop test. The abdomen was insufflated with C02 and an 8 mm port was inserted. Intra-abdominal placement was confirmed via direct visualization with the laparoscope. Under direct visualization, two 8 mm lateral ports were placed 10 cm from the midline and above the anterior superior iliac spine. A 5 mm assistant port was placed on the left side between the scope and the lateral port. A fourth Davinci port was placed in the left lower quadrant, for the third arm.

The robot was docked. Monopolar scissors and the PK cautery forceps were introduced through the 8 mm DaVinci ports and attention was turned on to the console.

Examination of the pelvis and abdomen revealed a large 4-5 cm fundal fibroid and a 2-3 cm anterior fibroid. There was a 2 cm fibroid in the posterior cervix.

The Filshie clips were identified attached to the mesosalpinx at about the midportion of each fallopian tube. These were easily excised from the mesosalpinx with the monopolar scissors, and each was removed from the abdomen. They were included with the pathologic specimen at the conclusion of the procedure.

A dilute solution of vasopressin (20 units diluted in 200 mL of injectable saline, total volume used 20 mL) was injected in the sub-serosal plane and myometrium along the periphery of the fundal fibroid.

The serosa was opened in a vertical axis in the anterior uterus and fundus. The fibroid was dissected out of the myometrium using the PK and monopolar scissors. It was about 5-6 cm. The dissection was accomplished by inserting the PK into the capsule plane and manipulating it so as to free the myoma. A combination of PK bipolar and monopolar cautery was used to achieve hemostasis. Once it was removed from the myometrium a second 2-3 cm fibroid was dissected out of the lower anterior myometrium, through the same incision, using the same technique. The fibroids were placed in the posterior cul-de-sac for later removal from the abdomen.

The myometrial incision was closed in 3 layers with running 2-0 V-lock suture. The pelvis was irrigated and hemostasis was achieved with monopolar cautery. Arista was applied for additional hemostasis along the incision line.

The assistant port was swapped out for a 12 mm port. An endoscopic baggie was inserted. The fibroids were placed in the baggie. The assistant port was enlarged to 4 cm such that the baggie containing the fibroids could be removed from the abdomen. To facilitate specimen removal the fibroid was morcellated inside the baggie (a spiral cut) with an 11-blade scalpel.

So should I report 58662?

Answer: You should not report 58662 (Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method), since the clips are not a lesion, and the ob-gyn easily removed them.

If the ob-gyn does this procedure by itself, you would have report the unlisted code 49329 (Unlisted laparoscopy procedure, abdomen, peritoneum and omentum).

You can try that or try the modifier 22 (Increased procedural service) approach for significant additional work to the myomectomy such as 58545 (Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas) .

However, your ob-gyn has described the clips removed "easily" so you may get ignored for additional payment so matter which way you choose because the payer may consider this "incidental" work. In addition, you have provided no medical indication for their removal which would also be a problem in trying to bill for theirremoval.