Highlighting 4 Factors to Pinpoint Which Hysterectomy Code to Use
Discover essential insights for coding hysterectomies in medical billing. Learn about the four key factors—approach, uterine size, extent of the procedure, and additional surgeries—that impact coding accuracy and reimbursement.
OB/GYN Medical Billing & Coding Alert
Caution: The weight of fibroids should not be included when calculating the weight of the uterus.
Around 600,000 hysterectomies are performed each year in the United States, so it's likely that a hysterectomy claim will cross your desk at some point. Before feeling overwhelmed by the numerous procedural options, focus on isolating these four key factors of the procedure:
- Approach
- Size/weight
- Extent of the uterus removed
- Additional procedures performed
Factor 1: Determine Your Ob/gyn’s Approach
Start by identifying the approach your ob/gyn used for the procedure. This step is essential as it will guide you in selecting the appropriate code series for accurate documentation.
Open Procedures: If your OBGYN performed the hysterectomy via an abdominal approach, refer to code series 58150-58240 or 58951-58956 if it was done due to malignancy.
For a hysterectomy performed by your OBGYN using a vaginal approach, look to the 58260-58294 code series.
Laparoscopic Procedure
- For a laparoscopic-assisted vaginal hysterectomy (LAVH), use codes 58550-58554.
- If your ob/gyn performed a supracervical laparoscopic hysterectomy, select one of the codes from 58541-58544.
- For a total laparoscopic hysterectomy, refer to codes 58570-58575.
Why This Matters: Laparoscopic hysterectomies differ significantly from those done through a laparotomy incision, often resulting in higher relative value units (RVUs) and increased reimbursement for open procedures involving similar work.
Factor 2: Check the Report for Uterine Size
For many hysterectomy procedures, knowing the weight of the uterus—specifically, whether it’s 250 grams or less or over 250 grams—is crucial to narrowing down the correct coding.
If the uterus weighed 250 grams or less, use codes 58260-58270 for vaginal approach procedures, 58550-58552 or 58570-58571 for laparoscopic approaches, or 58541-58542 for a supracervical laparoscopic hysterectomy.
If the uterus weighed over 250 grams, use codes 58290-58294 for vaginal approach procedures, 58553-58554 or 58572-58573 for laparoscopic procedures, or 58543-58544 for a supracervical laparoscopic hysterectomy.
Why This Matters: Not knowing the weight of the uterus can lead to missed reimbursement opportunities. Melanie Witt, RN, MA, an independent coding expert, recommends ensuring the pathology report consistently includes the uterine weight.
Caution: The presence of fibroids can increase the uterine weight when internal or within the uterine walls. Witt advises that if fibroids are removed as a separate specimen, their weight should not be combined with the uterine weight to determine the code for the hysterectomy.
Factor 3: Confirm Your Codes Reflect the Hysterectomy’s Extent
In some cases, an open or laparoscopic hysterectomy may involve more than just the removal of the uterus.
For example, a hysterectomy may be a total or a subtotal (or supracervical) abdominal hysterectomy, which you would code with 58180. This code, for a supracervical abdominal hysterectomy, includes the removal of the uterus (fundus) but leaves the cervix intact, with or without removal of the fallopian tubes or ovaries. This procedure involves transecting the uterus just below the internal os, meaning your ob/gyn removes the uterus while leaving the cervix.
Factor 4: Pause Before Coding Additional Procedures
Important: If the code description includes "with or without removal of tubes and ovaries," you should not code separately for removing these structures.
Also, you cannot separately code for fibroid removal when the ob/gyn removes the uterus, regardless of the method used, advises Melanie Witt.
Practice Example
After reviewing the guidelines for finding hysterectomy codes, try applying them to this example.
Question Highlighting 4 Factors to Pinpoint Which Hysterectomy Code to Use
How would you code a vaginal hysterectomy for a uterus weighing less than 250 grams, without removal of tubes and ovaries?
Factor 1: Since this is a vaginal hysterectomy, you will refer to code series 58260-58294.
Factor 2: From these codes, only 58260-58270 correspond to a uterus weighing less than 250 grams.
Factor 3: The extent of this procedure did not involve the removal of tubes or ovaries. Therefore, the appropriate code is 58260 (Vaginal hysterectomy for a uterus weighing 250 grams or less).
Factor 4: If this example had included an additional procedure, such as an enterocele repair or a colpourethrocystopexy, it would have influenced your coding for the hysterectomy.
Note: In the next issue of the Ob/gyn Coding Alert, we will explore how to approach coding when additional procedures accompany your hysterectomy services. Stay tuned!
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