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Posted By Maria on 01-19-2021, 09:34:08 in Ob-Gyn
Hello Melanie,

What CPT code would you use for a myomectomy abdominal with no intramural fibroids?

Findings: Heterogenous, fibroid uterus up to the xyphoid. Large pedunculated fundal fibroid and multiple large subserosal and submucosal fibroids throughout the corpus of the uterus.
 
Procedure Details: The patient was taken to the operating room and placed in the dorsal supine position. General endotracheal anesthesia was administered without difficulty. Cefoxitin 2 g IV and 500mg Flagyl was given for infection prophylaxis. She was prepped and draped in the normal sterile fashion. A Foley catheter was also placed. A Time-Out was then performed. Abdominal exam under anesthesia revealed a large uterus extending to the xyphoid.
 
A vertical midline incision was made with the scalpel and carried down to the fascia using the bovie. The fascia was incised and extended with the scalpel. The fascial edges were then grasped with Kocher clamps, and the underlying muscles were dissected off bluntly. The peritoneum was entered sharply and extended wih manual traction and Metzenbaum scissors.
 
The uterus was immediately visualized and it was delivered. The above findings were then noted. The large pedunculated fibroid was removed first. The base was clamped with large kelly clamps and the fibroid was removed using the bovie. 0-vicryl was used to suture ligate the pedicle. Attention was next turned to the corpus of the uterus which contained many fibroids. Vasopressin was injected into the first fibroid. The uterine serosa was incised with the bovie and carried down to the fibroid capsule. The fibroid was then excised with blunt and sharp dissection. Care was taken to remove as little myometrium as possible along with the fibroid. Multiple fibroids were removed through this incision and through the defect in the endometrium that was created. This was repeated for each fibroid. A total of three serosal incisions were made: at the fundus, anterior midline, and right lateral. A total of 28 uterine fibroids were removed in the fashion described above. The endometrium was entered in the process due to the large size and volume of fibroids. When all the fibroids that could safely be removed were out, we then began to close the uterus. We began with the midline anterior incision. The deep myometrium was closed using interrupted 0-vicryl to reapproximate the tissue. Next, the superficial myometrium and serosa were closed using 0-vicryl in a running locked fashion. Hemostasis was observed and attention was then turned to the right lateral incision. The deep myometrium was again closed using interrupted 0-vicryl sutures. The superficial myometrium and serosa were then reapproximated using 0-vicryl. Hemostasis was observed. Attention was next paid to the fundal defect. The deep myometrium was closed in a running fashion using 0-vicryl. The superficial myometrium and serosa were closed with 0-vicryl in a running fashion. The uterus was inspected and hemostasis was observed using the bovie and several interrupted figure of eights using 0-vicryls. Copious irrigation was performed. The uterus was replaced into anatomical position and reinspected for hemostasis. There was some bleeding noted on the right lateral incision so additional 0-vicryl was placed to achieve meticulous hemostasis. Intercept was placed over each of the hysterotomies and surgicel powder was applied.
 
The peritoneum was grasped with hemostats and 2-0 vicryl was used to reapproximate it. The fascia was closed with 0 vicryl in a running fashion. The subcutaneous tissue was irrigated with a sloppy wet lap sponge, and any bleeding points were cauterized with the bovie. The subcutaneous tissue was reapproximated with 3-0 plain gut in an interrupted fashion.

Path
Received in formalin, labeled fibroids (28) are 28 whorled, tan nodules
that have a total weight of 1,360 gm.  20 of the nodules range from 1 cm
to 5 cm.  Seven of the nodules range from 5 to 8.5 cm.  The largest nodule
is 15 x 9 x 8 cm.  25 of the nodules, including the largest nodule, have
whorled, white-tan cut surfaces.  Two of the nodules have pink-gray,
whorled surfaces.  These two nodules are 4 cm and 5 cm in diameter.  The
remaining nodule has focally mineralized cut surfaces and is 3 cm in
diameter.  Additionally submitted are multiple fragments of rubbery, tan,
fibromembranous tissue that measure in aggregate 9 x 7 x 2 cm.
Representative sections are submitted in 16 cassettes as follows:  
Cassette 1:  Four nodules.
Cassette 2:  Four nodules.
Cassette 3:  Three nodules.
Cassette 4:  Three nodules.
Cassette 5:  Three nodules.  
Cassette 6:  Three nodules.
Cassette 7:  One nodule.
Cassette 8:  One nodule.
Cassette 9:  One nodule.
Cassette 10:  One nodule.
Cassettes 11-12:  Largest nodule.
Cassette 13:  One gray nodule.
Cassette 14:  Other gray nodule.
Cassette 15:  Mineralized nodule following decalcification.
Cassette 16:  Separate tissue fragments
 
Thank you! Maria
Comments (1)
Posted By Melanie Witt on 01-19-2021, 14:15:01
Despite the weight, the code 58146 stipulates there must by intramural fibroids present to report it. I would say 58140-22 in this case as this was a lot of extra work.
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