Wiki Need help with surgery coding

[lsauseda]

Hello everyone! I'm an ortho coding who was asked to assist on a womens clinic operation. I'm a bit clueless when it comes to these so I figured I could come here for help. I have no clue how to code this so any help would be greatly appreciated.

Post-Operative Diagnosis:
Menorrhagia with anemia and history of severe pelvic endometriosis.

Procedure Performed:
Laparoscopic assisted vaginal hysterectomy, left salpingo-oophorectomy and extensive amount of lysis of adhesions lasting about an hour and a half.

Thanks in advance!

 

[RFoster1]

58552 - if uterus was 250g or less
58554 - if uterus was greater than 250g

Unfortunately you cannot code separately for lysis of adhesions but you can add a 22 modifier to your procedure code.


626.2
285.9
Unsure if the history dx will be needed

 

[dmaguire]

I did not think endometriosis ever really goes away? If I am correct you would code for endometriosis.

As far as the modifer 22 the provider has to have an additional statment in his op note to support coding for additional work. My breast care providers bill for additiona work when they do skin sparing, nipple sparing mastectomies. The required statement is:" Because this was a skin and nipple sparing mastectomy, the amount of time and energy and skill required to perform this particular procedure was 50% more than performing a simple mastectomy. For this reason, modifier 22 was used." When I worked for a general surgerons office who did laproscopic procedures I had a provider who felt that everytime he had "extensive lysis of adhenisons" he should use the 22 modifier. It has to be 50% more additonal work which also means at least 50% longer than a typical case would take.

When we bill with the modifer 22 we also send the notes along.

Danielle