GCandy
Contributor
Which is most important, the procedure or the approach?? Surgeon performs a 58571 in May. In July, he takes the patient back to OR and bills a 58548-52. He is now billing a Laparoscopic radical parametrectomy, upper vaginectomy, bilateral pelvic lymph node dissection. Cystotomy and repair (incidental). This is the scenario:
Procedure Code(s) Reported by Provider
58548 – 52 Laparoscopy, Surgical Radical Hysterectomy, w/bilateral total pelvic Lymphadenectomy and para-aortic lymph node sampling, with removal of tubes(s) and ovary(s).
Diagnosis Code(s) Reported by Provider
180.0 Malignant Neoplasm Endocervix
Procedure Code(s) Supported by Documentation
57109 -Vaginectomy; Partial removal of Vag Wall, with removal of paravaginal tissue (radical vaginectomy; with bilateral total pelvic Lymphadenectomy and para-aortic lymph node sampling
51860 Repair of Bladder Wound
49321 Laparoscopy Surgical w/biopsy
Diagnosis Code(s) Supported by Documentation
233.39 Carcinoma in situ Other female genital organ
233.2 Carcinoma in situ other and unspecified parts of uterus
The Surgeon feels that the Lap-Hyst code reduced best fits the procedure since there is no code for the parametrectomy and the 57109 is an open procedure. Any other views?
Procedure Code(s) Reported by Provider
58548 – 52 Laparoscopy, Surgical Radical Hysterectomy, w/bilateral total pelvic Lymphadenectomy and para-aortic lymph node sampling, with removal of tubes(s) and ovary(s).
Diagnosis Code(s) Reported by Provider
180.0 Malignant Neoplasm Endocervix
Procedure Code(s) Supported by Documentation
57109 -Vaginectomy; Partial removal of Vag Wall, with removal of paravaginal tissue (radical vaginectomy; with bilateral total pelvic Lymphadenectomy and para-aortic lymph node sampling
51860 Repair of Bladder Wound
49321 Laparoscopy Surgical w/biopsy
Diagnosis Code(s) Supported by Documentation
233.39 Carcinoma in situ Other female genital organ
233.2 Carcinoma in situ other and unspecified parts of uterus
The Surgeon feels that the Lap-Hyst code reduced best fits the procedure since there is no code for the parametrectomy and the 57109 is an open procedure. Any other views?