You can post a question only up to 7 days from the date of the webinar.
You can continue to post comments and stay informed, compliant, and profitable.
Close
This session has expired.
Register for our upcoming webinars & continue to get coding, compliance & reimbursement updates.
Close

Post

Vote
0
2 Followers Follow
Posted By Maria on 01-27-2021, 11:01:35 in Ob-Gyn
Melanie,

Would you please help me code this surgery? I have worked with this one for two days and keep going around in circles. Trying to get the most RVUs.

Procedure(s):
Robotic Assisted Laparoscopic Modified Radical Hysterectomy, Bilateral Salpingo-Oophorectomy, Right parametrectomy, Pelvic and para aortic lymphadenectomy, Optimal tumor debulking, omentectomy, Argon Beam Ablation, Right ureterolysis, Cystoscopy

Survey of the pelvis revealed the above findings. The small intestine was retracted up into the upper abdomen for visualization of the aortic bifurcation. The robot was then docked in standard fashion. Pelvic washings were obtained.
 
The adhesions between the uterus and the rectosigmoid were lysed with sharp and cautery dissection, care was taken to avoid injury to the bowel.
 
Extensive lysis of adhesions of the right ovarian mass to the pelvic side wall, uterus, rectosigmoid and right ureter.
 
The right round ligament was then divided and the posterior aspect of the broad ligament was taken down to the level of the external iliac parallel to the IP ligament. The pararectal and paravesical spaces were then developed identifying the course of the ureter.
The ureter was identified and a window made into the posterior aspect of the broad ligament, which skeletonized the IP. Right ureterolysis was performed along the course of the ureter in the pelvis, the right uterine artery was bipolar cauterized and cut at its origin. The IP was further skeletonized, bipolar cauterized and transected. The remaining aspect of the posterior broad ligament was then taken down to level of the Vcare ring. Th right utero ovarian ligament was bipolar cauterized, cut with the tube. The right ovarian mass was placed in an endo catch bag. The bladder flap was created sharply. The uterine arteries were then skeletonized, bipolar cauterized and transected.
 
The left round ligament was then divided and the posterior aspect of the broad ligament was taken down to the level of the external iliac parallel to the IP ligament. The pararectal and paravesical spaces were then developed identifying the course of the ureter.
The ureter was identified and a window made into the posterior aspect of the broad ligament, which skeletonized the IP. The IP was further skeletonized, bipolar cauterized and transected. The remaining aspect of the posterior broad ligament was then taken down to level of the Vcare ring. The bladder flap was created sharply. The uterine arteries were then skeletonized, bipolar cauterized and transected.
 
 
A circumferential colpotomy made around the Vcare. The uterus, cervix, tubes and ovaries were then delivered through the vagina. The colpotomy was reapproximated with 2/0 V-lock suture running fashion.
 
The right pelvic lymph node dissection was then performed from the mid common iliac artery along the external iliac artery to the circumflex iliac vein, medially along the external iliac vein down to the level of the obturator nerve, medially to the ureter. The right pelvic lymph nodes were then placed in an Endocatch bag. A similar procedure was performed on the contralateral side.
The obturator and genitofemoral nerves were found to be intact by the end of the procedure.
 
A right periaortic lymph node dissection was then performed from the mid common iliac artery along the order to the level of the retroperitoneal duodenum over the vena cava and laterally to the right ureter and psoas. These were placed in an Endocatch bagand removed from the abdominal cavity.
Omentectomy was performed with bipolar cautery and scissors and was placed in an endo catch bag.
 
 
Extensive tumor involving the right parametrium and para rectal space that was dissected carefully with electrocautery and scissors.
 
Argon beam ablation was performed to the bed of the disease are removed in the right parametrium and right pararectal spaces.

Path
A. Right ovary and fallopian tube, salpingo-oophorectomy: Poorly differentiated carcinoma of the ovary, see comment. Fallopian tube, positive for carcinoma. Tumor size is 9.0 cm. Please see synoptic report.
 
B. Uterus and cervix, Left fallopian tube and ovary, hysterectomy with left salpingo-oophorectomy: Uterus, left ovary and left fallopian tube, negative for carcinoma. Benign endometrial polyp. Mild cervicitis.
 
C. Right pelvic lymph node, excision: One lymph node, negative for malignancy (0/1).
 
D. Right pelvic wall tissue, biopsy: Positive for metastatic poorly differentiated carcinoma.
 
E. Right parametrium: Positive for metastatic poorly differentiate carcinoma

F. Right pararectal tissue: Positive for metastatic poorly differentiated carcinoma.
 
G. Right infundibulopelvic ligament, biopsy: Positive for metastatic poorly differentiated carcinoma.

H. J. Omentum, resection: Negative for malignancy.

Thanks so much, Maria






 


Comments (2)
Posted By Maria on 02-01-2021, 14:48:46
Hello Melanie,

I can not thank you enough for that explanation. The way you broke it all, made such sense to me. You have helped me so much for years now. I just want you to know, you are very appreciated!!
Posted By Melanie Witt on 01-29-2021, 14:41:33
For the basic procedure you have 2 options: 58575 or 58548. Per the CPT Assistant: Code 58548, Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed, is used to report radical hysterectomy; while code 58575, Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed, is used to report total hysterectomy. Code 58548 describes a procedure typically performed for early stage cervical cancer that includes radical hysterectomy (removal of uterus and cervix, bilateral parametria and upper vagina) as well as pelvic and para-aortic lymph node sampling (biopsy). This procedure does not include an omentectomy. If the surgeon performs omentectomy, modifier 22, Increased procedural services, is appended to report the additional work. Code 58575 describes a procedure that includes removal of the tumor (often seen in advanced gynecologic cancer), and typically after neoadjuvant chemotherapy. In addition, code 58575 includes resection of the uterus, cervix and adnexa, as well as tumor implants; and typically, removal of the omentum. However, unlike code 58548, code 58575 does not include removal of the bilateral pelvic lymph nodes and sampling of the para-aortic lymph nodes.

So lets examine the differences. The radical code, 58548 includes the hysterectomy, parametrectomy, and lymph node removal, but does not include parametrectomy or the debulking. And in fact there is no separate code for a laparoscopic omentectomy or tumor debulking by itself. This code has 55.15 RVUS and you only choice there would be to add a modifier -22 to account for the additional work. The cystoscopy is not described so I would assume was done to check his work and running the ureter is part of any procedure to avoid cutting it during the surgery so you can't bill for that either.

The code 58575 is not a radical procedure so does not include the parametrectomy or the lymph nodes, It has 56.41 RVUs so captures for of the work and you could also bill 38572 for the lymph nodes with 26.56 RVUS. This would be my choice to maximize reimbursement. You might want to add a modifier -22 to 58575 to account for the additional work.
Do you want to remove this attachment from this post?
Yes No
Do you want to add this specialty to your selected specialty list?
Yes No
To comment, please register for any of our webinars. Click here to register for our upcoming webinars.
Close
This comment will be permanently deleted. Do you still want to continue?
Yes No
Do you want to remove this comment from this discussion?
Yes No
Do you want to block this user from participating in this discussion?
Yes No
Do you want to allow this user to participate in this discussion?
Yes No
This post will not be available for further discussion/comments if deleted. Do you still want to continue?
Yes No