Wiki Case #16 Winner, Answer Key, & Rationale

alex.mckinley@aapc.com

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Chelsi T. is our case #16 champion. See below for the answer key and rationale.

ANSWER KEY
CPT: 58554
CPT Modifiers: none
ICD-9: 621.30

RATIONALE
The provider performs a laparoscopic-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy. The codes for hysterectomy are selected based on approach and weight of the uterus which is 260 g in this case. The postoperative diagnoses documented include endometrial hyperplasia and postmenopausal bleeding. According to the Official Coding Guidelines, do not report codes for signs and symptoms when a definitive diagnosis is determined. Postmenopausal bleeding is a symptom of endometrial hyperplasia. The only diagnosis code reported is endometrial hyperplasia.

CPT: 58554

Steps to look up: Hysterectomy/Vaginal

ICD-9-CM: 621.30

Steps to look up: Hyperplasia, hyperplastic/endometrium, endometrial
 
I coded the postmenopausal bleeding. Those of us who aren't physicians may not know that this is a symptom of the hyperplasia...unless you work at an OB-GYN office where this is a regular occurrence. I find it especially confusing since the report itself indicated them to be two separate diagnoses. Maybe they shouldn't have been listed this way if you didn't want both codes.
 
Agreed... I also coded the post menopausal bleeding and that's how we would have coded it if it was listed as it is shown, and I worked in OB/GYN office for 15 years.
 
Signs and symptoms

I to coded for the post menapausal bleeding. While I can understand the thinking behind the answer and this specific code does not have a LCD. I do not like that in order for some procedures to be paid, Medicare requires us to code for signs and symptons when we already have the specific dx.
 
Case 16

I too also coded the postmenopausal bleeding dx because I did not realize it was a symptom of the "main dx" I enjoyed the coding challenge but I disagree with a few of the codes and dx: There were not enough information given or even in one of them it was said that no lysis of adhesions were done and then the next sentence it states there were lysis of adhesions.

On the other hand it was fun and challenging and I did learn some things.
 
Case # 16 clinical added to Answer key & Rationale

Case # 16 clinical added to Answer key & Rationale
Since the clinical info wasn't included in posting of answer & rationale; and the link to case clinical info given now is not accessible (error page shows up) .... I thought it wise to include the missing clinical info.

See below for the answer key and rationale.

ANSWER KEY
CPT: 58554
CPT Modifiers: none
ICD-9: 621.30

RATIONALE
The provider performs a laparoscopic-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy. The codes for hysterectomy are selected based on approach and weight of the uterus which is 260 g in this case. The postoperative diagnoses documented include endometrial hyperplasia and postmenopausal bleeding. According to the Official Coding Guidelines, do not report codes for signs and symptoms when a definitive diagnosis is determined. Postmenopausal bleeding is a symptom of endometrial hyperplasia. The only diagnosis code reported is endometrial hyperplasia.

CPT: 58554

Steps to look up: Hysterectomy/Vaginal

ICD-9-CM: 621.30

Steps to look up: Hyperplasia, hyperplastic/endometrium, endometrial





Hint: Case 16 in another operative report and involves a hysterectomy.



Case #16

ANESTHESIA PERFORMED: General

PREOPERATIVE DIAGNOSES: Endometrial hyperplasia, postmenopausal bleeding

POSTOPERATIVE DIAGNOSIS: Endometrial hyperplasia, postmenopausal bleeding

PROCEDURE PERFORMED: Laparoscopic-assisted vaginal hysterectomy (LAVH), bilateral salpingooophorectomy (BSO).

COMPLICATIONS: None

ESTIMATED BLOOD LOSS: 50 cc

URINE OUTPUT: 100 cc

FLUID: 1200 cc of crystalloid

Uterus: 260 g

FINDINGS: Normal-appearing uterus and ovaries bilaterally

INDICATIONS FOR PROCEDURE: The patient is a 76-year-old gravida 3, para 3, who has had on and off postmenopausal bleeding for a number of years. She has had office and endometrial biopsies as well as hysteroscopy, D and C with recurrence of postmenopausal bleeding this time and a thickened lining of 1 cm. The patient elected to proceed with definitive surgical management. She was counseled extensively on risks, benefits, alternatives to laparoscopic-assisted vaginal hysterectomy with bilateral salpingooophorectomy and signed consent.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was found to be adequate. She was prepped and draped in a normal sterile fashion. Legs were placed in Allen stirrups, and a Foley catheter was inserted. Attention was first turned vaginally where a speculum was inserted and a uterine manipulator placed. Attention was then turned abdominally where a 5-mm infraumbilical incision was made using a scalpel. Using the Visiport, the scope and port were introduced under direct visualization into the peritoneal cavity. Peritoneum was then insufflated with CO2 gas to approximately 30 mmHg pressure. The abdomen was transiluminated in the left lower quadrant. A 5-mm incision was made and a 5-mm Apple port placed again under direct visualization. This was repeated on the right side. Attention was first turned to the right IP ligament. It was isolated and tented using the Allis clamp and transected using the Harmonic Scalpel. The round ligament was similarly identified and isolated and transected using the Harmonic Scalpel. The anterior portion on the right of the bladder flap was then created using the Harmonic Scalpel. Attention was then turned to the left where similarly using an Allis clamp, the IP ligament was isolated and tented. The Harmonic scalpel was used for cautery and transection. The round ligament was then isolated and again using the Harmonic, transected. Remainder of the bladder flap was then created using the Harmonic Scalpel. All pedicles were then inspected and found to be hemostatic. Attention was then turned vaginally where the weighted speculum was inserted. The cervix was grasped with a Jacobs retractor and circumscribed using the Bovie cautery. Posterior aspect of the vaginal area was then grasped and the posterior peritoneum posteriorly. Anteriorly, the peritoneum was the identified. Two Heaney clamps were used at either angle of the uterosacral ligaments and transected using Mayo scissors, sutured using 0 Vicryl. At this time, the anterior peritoneum was entered under direct visualization. Two additional bites on the right and the left using the Heaney clamp to the uterine arteries up to the broad ligament, were then placed on either side, transected using Mayo scissors and sutured using 0 Vicryl. At this point, the area of the laparoscopic dissection was obtained. A final Heaney clamp was placed at the right angle, transected using Mayo scissors, and sutured using 0 Vicryl. The entire uterus, tubes, and ovaries were then removed vaginally. Pedicles were inspected vaginally and found to be hemostatic. The peritoneum was grasped anteriorly and then the cuff closed in a running locked fashion using a 0 Vicrylsuture. Final inspection of the vaginal cuff showed hemostasis.

Attention was then turned abdominally where the vaginal cuff was inspected and irrigated with normal saline solution and again found to be hemostatic. Both ureters were identified and visualized until mobilization was seen. Final inspection of all pedicles demonstrated hemostasis. The ports were removed under direct visualization. Abdomen was then cleared of all CO2 gas. The skin incisions were closed using 4-0 Monocryl suture using Mastisol and Steri-Strips. The vaginal cuff was inspected one final time and found to be hemostatic. All sponge, lap, and needle counts were correct x2, and the patient was transferred to recovery room in stable condition.

https://www.aapc.com/code/aapc-coding-challenge/cases.aspx
 
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