Naomi Posted Thu 14th of May, 2020 20:17:41 PM
How do we code a surgery procedure our OBGYN did 1. Laparoscopic bilateral tubal sterilization. 2. Cervical cone biopsy. 3. Excision of anterior vaginal wall lesion.
SuperCoder Answered Fri 15th of May, 2020 08:52:28 AM
Thank you for your question.
Based upon the above limited documentation, it will not be appropriate to provide you with the exact code(s) for procedures listed. Actual procedure code(s) may vary, based upon the detailed procedure note.
For Laparoscopic bilateral tubal sterilization, use CPT® code 58670 (Laparoscopy, surgical; with fulguration of oviducts (with or without transection))
For Cervical Cone biopsy, the procedure note should indicate the technique through which the biopsy was obtained.
For instance, Code 57460 (Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix)
Code 57455 (Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix)
Code 57500 (Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure) is simply a biopsy of the cervix by any method.
For Excision of anterior vaginal wall lesion, you may use 57135 (Excision of vaginal cyst or tumor)
Note: There might be some coding conflict between the procedure codes which may not allow reporting all the codes during the same surgical session. Hence, request you to provide some brief of the procedure note, so that we can assist you with more appropriate code(s).
Naomi Posted Mon 18th of May, 2020 14:11:29 PM
Procedure notes after the Bilateral tubal went like this: The anterior vaginal lesion was then visualize and grasped with an A llis claim. An elliptical incision was then made approximately 1 cm from the edge as it was excised using the Metzenbausm scissors. A full thickness of the vaginal wall was obtained in the specimen. The wound was then closed using a 2-0 Vircryl in running interlocking fashion obtaining hemostasis. The cervix was then stained with Lugol's solution. A suture was then placed using 0 Vicryl at the 3 o'clock and 9 o'clock positions for traction and hemostasis. The cervix was then infiltrated with 0.5% Xylocaine with epinephrine. A circumferentail incision was then made and the cone biopsy was then performed and removed. The specimen was then opened at the 12 o'clock position. Endocervical was then obtained and submitted separately. The denuded area of the cervix was then cauterized until adequate hemostasis and charring of the surface was noted. The sutures were then cut and left approximately 1 inch long. The Foley catheter was removed.
SuperCoder Answered Tue 19th of May, 2020 08:25:00 AM
Hope you’re doing well!
Thank you for providing additional information.
As per the above provided documentation, you may report CPT® code 58670 (Laparoscopy, surgical; with fulguration of oviducts (with or without transection)), for Laparoscopic bilateral tubal sterilization.
For cervical cone biopsy, report CPT® code 57520 (Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser), as the cone biopsy of endocervix was obtained through the circumferential incision.
For Excision of anterior vaginal wall lesion, you may use CPT® code 57135 (Excision of vaginal cyst or tumor), as an elliptical incision was made to obtain a full thickness of vaginal wall.
Note: There are no NCCI edit between the above suggested codes, so correlate the codes with your detailed procedure note.
Hope that helps!
Naomi Posted Tue 19th of May, 2020 13:15:59 PM
Yes, thank you.
SuperCoder Answered Wed 20th of May, 2020 01:58:03 AM
Thank you, happy to help.