Wiki Vaginal trachelectomy with laparoscopic lysis of abdominal adhesions

[CPCCODERII]

Patient presented for vaginal trachelectomy and the provider began the procedure by inserting lap scopes into the abdominal cavity and takes down abdominal adhesions from previous abdominal surgery. Provider uses the scope to visualize the removal of the cervix. Per documentation, the trachelectomy was performed vaginally, and not laparoscopically. We have been researching and are unable to find any information regarding what can be billed for the scope. Can we bill separately for the lysis of adhesions? It is difficult to determine why the provider placed the scope to complete the procedure and if the adhesions were incidental to moving the scope into a viewing position. Has anyone else ever coded a procedure like this? I can post an OP note if needed.

 

[Cmama12]

Hmm, well without seeing the note, I'd say if the scope was used during the procedure then it's a laparoscopic procedure and then it would be an unlisted code for a lap trachelectomy. Lysis is usually always included in the main procedure but can add a 22 modifier if documentation supports significant extra work.