Ob-Gyn Coding Alert

Question: Would CPT^® 58548 be appropriate for this case or 58571 and 38572?

PREOPERATIVE DIAGNOSIS: FIGO grade 2 endometrial carcinoma of the uterine corpus OPERATION:

1. Diagnostic laparoscopy
2. Total laparoscopic hysterectomy
3. Bilateral salpingo-oophorectomy
4. Successful bilateral sentinel lymph node mapping and dissection
5. Complete right para-aortic and common lymphadenectomy
6. Peritoneal washings

5mm skin incision was made 2cm below the costal margin in the mid-clavicular line. An OptiView trocar with the 5mm laparoscope was introduced into the abdomen under direct visualization. Peritoneal entry was confirmed visually, and the peritoneal cavity was then insufflated with C02 gas. A survey of the abdomen and pelvis was then performed with the above findings. There was no injury to visceral structures with laparoscopic entry. The remainder of the laparoscopic ports were then placed under direct visual­ization in a semilunar shape at the level of the patient’s mid-upper abdomen and the patient was placed in steep Trendelenburg.

We first proceeded with opening the retroperitoneum. The peritoneum lateral to the external iliac artery on the left was incised with Bovie electrocautery. The peritoneum was divided parallel to the gonadal artery and vein. The ureter was identified in the retroperitoneal space and the para-rectal space was developed. The superior vesicle artery was then mobilized to open the obturator space. The fluorescent filter on the camera was then used to identify a green node which was located at the bifurcation of the external and internal iliac vessels on the left. This nodal bundle was elevated away from the vascular structures and dissected away from them with care to identify and avoid the ureter. The node was removed and sent to pathology. The right retroperitoneum was also opened but no green nodes were seen in the pelvis after opening the para-rectal and obturator spaced. However, upon opening the retroperitoneum in the abdomen, green nodes were seen along the aorta. There were several positive-appearing lymph nodes, so we performed a right para-aortic lymphadenectomy. The ureter was mobilized laterally and the lymph nodes overlying the aorta and IVC were elevated and dissected away from these vascular structures with Ligasure. There was a concerning common iliac lymph node bundle, which was also dissected away from the artery with care to avoid the ureter and vein. In the pelvis there was a firm nodal bundle along the psoas muscle, which was also dissected and removed.

At this juncture, the green nodes and concerning lymph nodes had been removed. So we proceeded with the hysterectomy. On the right, an avascular plane superior to the ureter was excised to isolate the gonadal artery and vein. This was fulgurated and transected. This procedure was then performed on the left-hand side. The posterior peritoneum was then dissected bilaterally to the level of the uterine artery insertion. We then proceeded to dissect the vesicouterine peritoneum and bladder away from the lower uterine segment and cervix until the RUMI cervical cup was identified. The bladder was significantly scarred, consistent with her history of prior cesarean delivery. The bilateral uterine arteries and veins were isolated, fulgurated, and transected at the level of the internal cervical os. The cardinal ligaments and uterosacral ligaments were similarly fulgurated and transected. The vagina was excised over the cervical cup and the specimen was removed from the vagina and sent to pathology for review.

Illinois Subscriber

Answer: A radical hysterectomy must include the removal of not only the entire uterus and cervix, but also the parametrium — which is made up of the broad, round, cardinal, and uterosacral ligaments — and the upper one-third to one-half of the vagina. The documentation you have submitted does not mention removal any of the vaginal tissue. Therefore, you should go with 58571 (Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/ or ovary(s)) and 38572 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple).

Note that the statement at the end of the report, “The vagina was excised over the cervical cup,” does not constitute a description of the removal of part of the vagina, but rather implies separating the uterine specimen from the vagina.