Ob-Gyn Coding Alert

Question: My ob-gyn completed a vaginal hysterectomy of a uterus that was less than 250 grams. However, due to bleeding, the doctor opened the patient, controlled the bleeding and performed a left salpingo-oophorectomy (LSO) and right salpingectomy. Then he performed a colpopexy. How should I report this?

Connecticut Subscriber-

Answer: You must bill 58262 (Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube[s], and/or ovary[s]) for the hysterectomy part of this surgery.

The Correct Coding Initiative (CCI) bundles the open LSO code (58720, Salpingo-oophorectomy, complete or partial, unilateral or bilateral [separate procedure]) into the vaginal hysterectomy code 58260 (Vaginal hysterectomy, for uterus 250 grams or less).-Although the ob-gyn performs both procedures from two different approaches, the more complete code (58262) includes both procedures.

Controlling bleeding during the operation is just part of the surgical technique. Therefore, your ob-gyn won't get any credit for that.-

For the abdominal colpopexy, you should report 57280 (Colpopexy, abdominal approach). You will not get paid for this unless the surgeon documented a vaginal vault prolapse. Frequently, an ob-gyn will place these sutures to shore up the vault to prevent future prolapse. In this case, this service is normally not payable.