Part B Insider (Multispecialty) Coding Alert

Find out how the weight of myomas means more than the number of them.

Deciding which myomectomy code you'll report depends on three factors: the approach the ob-gyn uses, the number of the myomas, and their weight. Three steps show you how to translate this information into the correct CPT code every time.

Watch out: If your ob-gyn performs a hysterectomy, you won't report the myomectomy separately. First, Define Myomas and Their Types When your ob-gyn performs a myomectomy, he is removing myomas or uterine fibroid tumors. Knowing what type they are will help you to determine your myomectomy code.

Definition: Myomas (also known as leiomyomas, leiomyofibromas, fibroleiomyomas or fibroids) are the most common growth of the female genital tract. They are round, firm, benign masses of the muscular wall of the uterus and are composed of smooth muscle and connective tissue. You'll see different types of uterine fibroids based on their location:

• Intracavitary myomas are fibroids inside the uterus.
• Submucous myomas are partially in the uterine cavity and partially in the wall of the uterus.
• Subserous myomas are on the outside wall of the uterus.
• Intramural myomas are in the wall of the uterus; their size can range from microscopic to larger than a grapefruit. These take a lot more effort to remove than a surface myoma.
• Pedunculated myomas are connected to the uterus by a stalk and are located inside the uterine cavity or on the outside surface or may be found prolapsing through the cervix.

Myomas often cause or are coincidental with abnormal uterine bleeding, pressure or pain. They are also one of the most common reasons women in their 30s or 40s have hysterectomies. However, women who want to have children in the future or simply do not want their uterus removed look for alternative solutions. The following procedures describe abdominal, vaginal, and laparoscopic approaches.

Step 1: Differentiate 2 Abdominal Myomectomy Codes

When the ob-gyn performs an abdominal myomectomy, he surgically removes the myoma from the uterus through an incision in the abdomen. For this procedure, you'll report either 58140 (Myomectomy, excision of fibroid tumor[s] of uterus, 1 to 4 intramural myoma[s] with total weight of 250 grams or less and/or removal of surface myomas; abdominal approach) or 58146 (Myomectomy, excision of fibroid tumor[s] of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams; abdominal approach).

Highlight: These codes differentiate between the number of myomas (58140 for one to four; 58146 for five or more) and the total weight of intramural myomas (58140 for total weight of 250 grams or less; 58146 for total weight greater than 250 grams).

Caution: Code 58146 refers only to intramural myomas. For surface myomas removed via an abdominal approach, you can report only 58140 -- irrespective of the number or their collective weight.

Example: If the ob-gyn removes two intramural myomas with a total weight of 350 grams, "I would report 58146 because the weight is greater than 250 grams," says Jenny Baker, CPC, COBGC, CPC-I, professional services coder of Women's Health at Oregon Health and Sciences University in Portland. On the other hand, if the ob-gyn removes seven intramural myomas that weigh a total of 200 grams, again, you should report 58146 because the ob-gyn removed five or more intramural myomas. But if the ob-gyn removes seven surface myomas, you should report 58140 instead.

Step 2: Apply This Code to Vaginal Approach

You'll report 58145 (Myomectomy, excision of fibroid tumor[s] of uterus, 1 to 4 intramural myoma[s] with total weight of 250 grams or less and/or removal of surface myomas; vaginal approach) for a myomectomy via a vaginal approach.

Example: If the ob-gyn removes 20 subserosal or surface myomas, you'll report either 58140 or 58145, depending on whether the ob-gyn used an abdominal or a vaginal myomectomy approach.

But what if total weight is more than 250 grams? You have one vaginal approach code for the removal of myomas. Generally, myomas larger than 250 grams require an abdominal or laparoscopic approach. But if your ob-gyn has documented this approach for a larger myoma, you could consider reporting a modifier 22 (Increased procedural service). Keep in mind: Your ob-gyn must sufficiently document this additional work.

Step 3: Learn These Laparoscopic Myomectomy Basics

Finally, you've got two laparoscopic approach myomectomy codes.

A laparoscopic myomectomy is a less invasive procedure than the abdominal myomectomy. This approach is usually an option for women who have conditions that preclude the vaginal route while still enabling them to avoid major abdominal surgery.

Usually, pedunculated myomas are the easiest for ob-gyns to remove laparoscopically, but ob-gyns will also use this approach for subserous myomas. For this procedure, you'll report either 58545 (Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 grams or less and/or removal of surface myomas) or 58546 (... 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams).

Difference: You'll report 58545 when the ob-gyn removes one to four intramural myomas with a total weight of 250 grams or less, and you'll report 58546 when the ob-gyn removes five or more intramural myomas or intramural myomas with a total weight greater than 250 grams. And as with the abdominal procedure, you can only report the removal of surface myomas with 58545 for this approach.

Avoid Myomectomy Codes with a Hysterectomy

When your ob-gyn performs a hysterectomy, both the laparoscopic and open excisional myomectomies are inherent components.

Payers will consider the removal of the myomas prior to the removal of the uterus as an inclusive component of the complex vaginal and excisional hysterectomy procedure codes (58260-58294, 58553-58554) and the total abdominal hysterectomy and radical pelvic exenteration codes (58150- 58240). Therefore, you should not report the removal of myomas separately to the hysterectomy procedure codes.

Exception: Watch out for the removal of a pelvic mass prior to hysterectomy. On rare occasions, the myoma is not attached to the uterus but to a neighboring structure. This requires the ob-gyn to remove it separately from the uterus. In that case and with clear supporting documentation, you can bill additionally.