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Posted By Mary Peabody on 12-12-2019, 19:50:51 in Ob-Gyn
Hello Melanie

If a Laparoscopic Total Hysterectomy with BSO and Laparoscopic excision of endometriosis is performed, would you code both 58571 and 58662. Would the excision or shaving of deeply infiltrative endometriosis along the uterosacral ligaments be separately coded with 58662?

Operative report attached

Stage IV endometriosis
* Deeply infiltrated endometriosis
* BiProcedure(s) and Anesthesia Type:
* LAPAROSCOPIC TOTAL HYSTERECTOMY, BILATERAL SALPINGECTOMY, AND LEFT OOPHORECTOMY - Anes-General
* LAPAROSCOPIC ENDOMETRIOSIS EXCISION - Anes-General
* CYSTOSCOPY (CYSTOURETHROSCOPY) WITH HYDRODISTENSION lateral ovarian endometrioma
FINAL PATHOLOGIC DIAGNOSIS

A. Uterus with left adnexa and right fallopian tube, hysterectomy, left
oopherectomy and bilateral salpingectomy:
- Left ovary:  
1. Endometriosis.
2. Hemorrhagic follicle cysts.
3. Surface adhesions.
- Fallopian tubes: Serosal adhesions.
- Endometrium:  Proliferative pattern.
- Myometrium:  Adenomyosis.
- Cervix:  No significant pathologic abnormality.
- Serosa:  Adhesions and endometriosis.

B. Right peri-ureteral peritoneum, excision: Fibromuscular connective
tissue with no significant pathologic abnormality.
 
C. Bladder peritoneum, excision: Fibrous connective tissue with
grannulation tissue and scar.      
 
D. Rectal serosa, excision: Organizing granulation tissue.
 
E. Bladder serosa, excision: Fibromuscular connective tissue with no
significant pathologic abnormality.
Comments (1)
Posted By Melanie Witt on 12-19-2019, 13:09:11
What is the op note description of the removal of the endometriosis and the findings statement? From the path report it looks like the endometriosis was removed with the uterus and tubes and the additional tissue was normal. Although there is no bundling edit for these 2 codes, there needs to be description of significant additional work in order to also bill 58662 with the hysterectomy in my opinion.
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