I was reading more about
NovaSure endometrial ablation to understand the difference between 58563 and 58353 CPTs and found a good example in Optum confirming CPT 58563. Apparently, even if MD removed hysteroscope to proceed with ablation that counts as hysteroscopic guidance= 58563. Thank you, Ms. Nielynco!
Date: |
01/18/2021 |
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Title: | Coding Scenario: Ablation of Endometriosis and Endometria |
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Source: |
AMA CPT book 2021; Optum ICD-10-CM Expert for Physicians 2021; ICD-10-CM Official Guidelines for Coding and Reporting 2021 |
Procedures Performed
Laparoscopy with lysis of adhesions
Holmium laser ablation of endometriosis
Diagnostic hysteroscopy
Dilatation and curettage
NovaSure endometrial ablation
Procedure
After induction of general anesthesia, the patient was placed in the supine lithotomy position. She then was prepped and draped in the usual sterile fashion. A 1 cm transverse infraumbilical skin incision was made through the patient's prior laparoscopy scar. An Endopath 10 to 12 mm trocar was passed with laparoscope under direct vision. I was able to pass through the fascia but encountered presumed preperitoneal adhesions. I still was able to pass into the peritoneal cavity. The trocar was removed and Veress needle was placed with good result on the hanging drop test. Carbon dioxide gas was infused with initial filling pressures of 7 up to final filling pressure of 14 mmHg. A bladed trocar was then passed without difficulty. The laparoscope was placed at appropriate location within the peritoneal cavity and was verified by direct visualization.
Exploration of the pelvis revealed adhesions of the right ovary, dense adhesions of the large bowel, and endometrial lesions as described. Marcaine 0.25 percent with epinephrine was used to anesthetize sites for two new 5 mm ports that were placed in the right and left lower quadrant under direct vision. The adhesion of the right ovary to the posterior aspect of the uterus appeared filmy and was excised with scissors. The holmium laser was used to ablate the peritoneal endometriosis lesions in the anterior and posterior cul-de-sac. The bowel adhesions of the left lower quadrant were examined. Some of these adhesions were able to be bluntly and sharply lysed. The bowel was densely adherent to the left posterior aspect of the uterus at the junction of utero-ovarian ligament, and we were unable to completely free it from attaching to the uterus. The trocars were left in position for revisualization following the endometrial ablation.
Gloves were changed and attention was turned to the hysteroscopic portion of the procedure. The uterus was anteverted and sounded to 11 cm. A single-toothed tenaculum was placed on the anterior lip of the cervix. The cervix was then dilated using Hanks dilators. The endocervical canal was measured at 4.5 cm. The diagnostic hysteroscope was passed, and the endometrial cavity was visualized. There was a minimal amount of endometrial tissue. There was a polypoid area near the right cornua. There was no impingement of the cavity by uterine fibroids. A 10 mm curette was passed into the uterus, and endometrial curettings were obtained and sent to pathology.
The NovaSure instrument was then placed. The endometrial length had been calculated at 6.6 cm and the width at 5.5 cm. Cavity assessment was satisfactory, and power was applied for 60 seconds at a power of 178. The NovaSure instrument was removed. The hysteroscope was passed again, and direct visualization of the uterus revealed adequate fulguration of the entire endometrial cavity up to the cornua bilaterally. The instruments were then removed from the cervix and uterus. There was no active bleeding.
The peritoneal cavity was visualized through the laparoscope at this point. There was no evidence of bleeding. The laparoscope and trocars were removed. Gas was allowed to escape from the endometrial cavity. The infraumbilical incision fascia was closed with 0 Vicryl and the skin with 4-0 Monocryl. The trocar incision skin was closed with 4-0 Monocryl. Steri-Strips and a sterile dressing were applied. The patient tolerated the procedure well.
Disposition
The patient returned to the postanesthesia care unit, was extubated, awake, and in stable condition.
CPT Code(s)
58662 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
58563-51 Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation)
Rationale
The first procedure was holmium laser ablation of endometriosis in the peritoneum. To locate this code, look in the CPT index under the term “Fulguration” and subterms “Lesion” and “Peritoneal,” which directs the coder to 58662. This code’s description in the female genital section of the code book describes a surgical laparoscopy with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method, which is appropriate.
A laparoscopy with lysis of adhesions was also performed but if the payer is Medicare or a payer that follows the 2021 Correct Coding Initiative (CCI) edits, an edit between codes 58662 and 49320 states that the two codes should not be reported together. As code 58662 describes the more comprehensive procedure, it is reported.
The next procedures were endometrial ablation and a hysteroscopy. The main term “Endometrial Ablation” and subterm “With Surgical Hysteroscopy” refer to code 58563. This code describes a surgical hysteroscopy with endometrial ablation (e.g., endometrial resection, electrosurgical ablation, thermoablation).
A dilatation and curettage (58356) was also performed but if the payer is Medicare or a payer that follows the 2021 National Correct Coding Initiative (NCCI) edits, an edit between codes 58563 and 58356 states that the two should not be reported together. Since code 58356 is considered an integral component of 58563, only code 58563 is reported.
The CPT codes are listed in the order of the highest relative value unit (RVU) to the lowest. Each code after the first must have modifier 51 appended to indicate that it describes a multiple procedure performed at the same session by the same physician. In this case, code 58563 is reported with modifier 51.