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Ob-Gyn Coding Alert

New Myomectomy Codes Require Complete Documentation to Ensure Proper Payment

Reviewed on May 20, 2015 The number and weight of excised myomas are the keys to reporting the new myomectomy codes introduced in CPT® 2003. Consequently, if your physician doesn't record this information, you may be forced to report lower codes, which will cut into your ob-gyn practice's bottom line. Ob-gyns perform myomectomies to surgically remove uterine fibroids (218.x), or myomas. The physician can take out the myomas either endoscopically, with a vaginal approach, or with an open procedure. Use 58140 for Open Abdominal Approach, but 58145 for Vaginal Approach. CPT® includes five codes for myomectomies. Three are new, and one is revised for 2003. The revised code, 58140 (Myomectomy, excision of fibroid tumor[s] of uterus, 1 to 4 intramural myoma[s] with total weight of 250 grams or less and/or removal of surface myomas; abdominal approach), previously did not specify the number or weight of the myomas, but only that the ob-gyn performed the procedure as an open abdominal approach. It now specifies one to four intramural myomas with a total weight of 250 grams. If the surgeon removes the myomas vaginally, you should use 58145 (…vaginal approach). You also should use these codes when the physician removes surface myomas. CPT® does not designate a particular number of surface myomas necessary for billing 58140 or 58145. This may be because "surface myomas do not take a whole lot of time, even if there are a whole bunch of them," says Melanie Witt, RN, CPC, MA, an ob-gyn coding expert. Coding Example: A 35-year-old woman reported to her ob-gyn for abnormal uterine bleeding. Although the physician has tried medications and dilation and curettage, they have not been successful in treating the condition. Using ultrasonography, the doctor finds three scattered intramural and subserosal myomata ranging in size from 1 cm to 5 cm. The ob-gyn decides to perform an open abdominal myomectomy because of the fibroids' location. In this case, you would report the myomectomy with 58140, linked with 218.1 (Intramural leiomyoma of uterus) and 218.2 (Subserous leiomyoma of uterus).  In ICD-10, you will use D25.1 (Intramural leiomyoma of uterus) and D25.2 (Subserous leiomyoma of uterus) instead.  New Code 58146 Represents Multiple/Large Myomas Code 58146 (Myomectomy, excision of fibroid tumor[s] of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 grams, abdominal approach) is brand new for 2003. You should use this code when the ob-gyn excises five or more uterine fibroid tumors. But remember that the documentation must state that they are intramural myomas. You also can bill this code if there are only one to four intramural myomas, but their total weight must be greater than 250 grams. As with 58140, 58146 represents [...]


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