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Posted By Mary Peabody on 02-21-2020, 14:55:56 in Ob-Gyn
Hello Melanie,

I am really confused regarding coding modified radical abdominal hysterectomy, CPT 58210-52 versus 58956. The path report showed
A. Omentum, omentectomy: Residual high-grade serous carcinoma,
status-post neoadjuvant chemotherapy; see comment.

B. Bladder implant, biopsy: Benign fibrous tissue with histiocytes and
hemosiderin, no residual viable tumor identified.

C. Uterus, c
PREOPERATIVE DIAGNOSIS:  high-grade pelvic cancer, s/p cycles of neoadjuvant chemotherapy with excellent response
 
POSTOPERATIVE DIAGNOSIS:  Same
 
OPERATION:   Exploratory laparotomy, modified radical abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, appendectomy, cystoscopy
We then proceeded with the laparotomy.  A midline incision was made from 2cm above the umbilicus down to the pubic symphysis.  This was carried down to the fascia with the Bovie electrocautery.  The fascia was incised and extended in a cephalad and caudad fashion.  The preperitoneal tissue was divided and the peritoneal cavity entered without incident.  We examined the upper abdomen as well as the pelvis, findings above.  We used a Bookwalter self-retaining retractor for exposure.  
 
We started with the omentum. I first mobilized the ascending colon in order to reach the hepatic flexure. On the left, the sigmoid was quite redundant and I did not need to mobilize it. We used monopolar to divide the avascular filmy connection on the underside of the transverse colon and we entered the lesser sac, which was free of disease. The transverse colon mesentery appeared normal. We then divided the omentum under the greater curvature of the stomach, isolating the gastro-epiploic vessels. The omentectomy was completed and sent for permanent sectioning.
 
We then packed the bowel and obtained exposure to the pelvis.  We used 2 curved Pean clamps to grasp the cornua of the uterus.  The round ligaments were suture ligated before being divided.  We extended the peritoneal incision parallel to the gonadal vessels and identified the ureter on the medial leaf of the broad ligament below the gonadal vessels.  We placed a Vesseloop around the ureter.  We identified And developed the pararectal and paravesical spaces, no enlarged nodes noted
 
I started on the left. The gonadal vessels had previously been identified, we isolated them, double-clamped, transected and suture-ligated the pedicle. We lifted the adnexa and divided the posterior peritoneum underneath toward the uterus at the level of the internal os, taking care to note the ureter well-below. I then incised the anterior peritoneum (the vesico-uterine peritoneum) and moblized the bladder down off the uterus and cervix. I then double-clamped, transected and suture-ligated the uterine artery pedicle. I used the LigaSure to divide the cardinal ligament and mobilize the uterine artery pedicle.
 
We then moved to the right side. The adnexal mass was stuck to the parametrium, necessitating a radical pelvic dissection and we did a modified radical hysterectomy on that side. We first isolated the gonadal vessels, doulbly clamped, transected and suture-ligated the pedicle, taking care to note the ureter well-below. I was able to take down some posterior peritoneum, but this was challenging as the mass did not lift up. We took down the vesicouterine peritoneum to mobilize the bladder away from the lower uterine segment and cervix. We identified the ureter and took the ureteral dissection down to the crossover of the cardinal ligament.  We identified the uterine artery crossing over the ureter and ligated and divided it with the LigaSure.  We then mobilized the parametria medially
while rolling the ureter laterally.  We carried out the ureteral dissection through the tunnel toward the bladder.  We mobilized the bladder away from the cervix and upper vagina. I then returned to the posterior peritoneal dissection, developing the rectovaginal septum from the right side. We were able to take our radical hysterectomy pedicles.  I used a 5mm blunt-tipped LigaSure on the uterosacral, parametrial, paracervical, and paravaginal pedicles on the right side until we reached the vagina.  We then placed 2 curved Zeppelin clamps across the upper vagina to give us a 1 cm margin.  We excise the uterine specimen and gave this to Pathology.  We closed the vaginal cuff using 0 PDS sutures in a running stitch.
 
We irrigated the pelvis and examined our vascular pedicles for good hemostasis.  We injected fluorescein.  A cystoscopy was performed. A well-lubricated 21 Fr rigid cystoscope per urethra and into the bladder. The urethra appeared to be normal without any lesions or erythema. A pancystoscopy revealed the bilateral ureteral orifices in their orthotopic positions. There were no masses, lesions, stones, or diverticuli. Bilteral ureteral orifices briskly effluxed bright yellow/green urine. The bladder distended and there was no leak, bladder was several centimeters from cuff closure.
 
Comments (1)
Posted By Melanie Witt on 02-26-2020, 12:54:21
A modified radical hysterectomy removes the uterus, cervix, upper part of the vagina, and ligaments and tissues that closely surround these organs, but in this type of surgery not as many tissues and/or organs are removed as in a radical hysterectomy. Nearby lymph nodes may also be removed. 58956 is not a radical procedure - the upper part of the vagina is not removed but the uterus, cervix and tubes and ovaries are removed a complete omentectomy is performed. With 58210 is for a radical procedure but includes the lymph nodes so a modifier -52 will usually mean you get half the allowable for the case as not only did he not do the nodes, he also did less than required for the radical. From the note it is not clear that he removed the upper part of the vagina and you did not include a description of the uterus that was submitted. He say he put clamps across the upper vagina to give them a 1 cm margin which is really a very tiny piece. You might be better off going with 58956-22 for the additional work in freeing up the adnexal mass.
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