Sandra Posted Sat 16th of January, 2016 14:15:40 PM
What cpt code would you recommend? My Doctor said to bill as a myomectomy?
Operative Laparoscopy resection of left uterine horn.
DX: Non-communicating left uterine horn. Bicornuate uterus. Hematometra with chronic pelvic pain?
The Operative Findings: The laparoscopy confirmed a 4-5 cm left non-communicating uterine horn with normal left ovary. There was a right horn contiguous with a single cervix and a normal right fallopian tube and ovary. The left uterine horn was resected without difficult. A hematometra was aspirated and the horn was removed from the abdomen through a 2-cm abdominal incision. The resulting pelvic anatomy was a normal right unicornuate horn and cervix with a normal right fallopian tube and ovary. The left fallopian tube and ovary remained and were noted high on the pelvic brim, but othersie were normal in appearance. The appendix and the liver edge were grossly normal.
SuperCoder Answered Mon 18th of January, 2016 04:38:38 AM
I think its not myomectomy as physician is not removing myoma.I think you can use code 58540 or 58541-52 modifier depending upon the approach physician used.