Medical Coding for Hysterectomy Procedures: A Comprehensive Guide

Overview of Hysterectomy

• • Hysterectomy is the second most common surgical procedure for women in the U.S., following cesarean sections, with approximately 600,000 performed annually.
  • Medical coders must understand the reasons for hysterectomy and the appropriate coding to ensure accuracy.

Reasons for Hysterectomy

• • Common indications include:
    • Endometriosis or uterine fibroids causing pain or bleeding
    • Uterine prolapse (sliding of the uterus into the vaginal canal)
    • Cancers of the uterus, ovaries, or cervix
    • Sterilization (inability to become pregnant)
    • Gender affirmation surgery

Common Additional Procedures

• • Hysterectomy may be performed with additional surgeries, such as:
    • Salpingectomy (removal of fallopian tubes)
    • Oophorectomy (removal of ovaries)
    • Vaginectomy (removal of all/part of the vagina)
    • Trachelectomy (removal of all/part of the cervix)
    • Lymphadenectomy (removal of lymph nodes)
    • Enterocele repair (repair of vaginal prolapse)

Key Factors for Accurate Coding

• • Surgical Approach: Determine whether the procedure is:
    • Laparoscopic
    • Vaginal
    • Abdominal
  • Extent of the Procedure: Specify the type of hysterectomy:
    • Total (entire uterus and cervix removed)
    • Subtotal/Supracervical (upper portion of the uterus removed, cervix left intact)
    • Radical (uterus, cervix, adjacent tissues, and upper vagina removed, often for cancer)

CPT Code Categories for Hysterectomy

• • Laparoscopic Hysterectomy:
    • Laparoscopic Supracervical (58541-58544)
    • Laparoscopic Assisted Vaginal Hysterectomy (58550-58554)
    • Total Laparoscopic Hysterectomy (58570-58573)
    • Laparoscopic Radical Hysterectomy (58548, 58575)
  • Abdominal Hysterectomy:
    • Total Abdominal Hysterectomy (58150-58240)
  • Vaginal Hysterectomy:
    • Vaginal Hysterectomy (58260-58294)
    • Vaginal Radical Hysterectomy (58285)
    • Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) (58260-58294)

Important Considerations in Coding

• • Uterus Weight: Some CPT® codes depend on the weight of the uterus. If not documented in the operative report, the weight can be taken from the pathology report, but it is preferred to use the operative report for accuracy.
  • Additional Procedures: Check for additional services performed during the hysterectomy, such as removal of fallopian tubes or ovaries, or enterocele repair. Ensure proper coding for any services that are separately reportable.

Innovations in Hysterectomy

• • vNOTES (Vaginal Natural Orifice Transluminal Endoscopic Surgery): A newer technique combining laparoscopic and vaginal approaches.
    • This procedure uses a laparoscopic device inserted via vaginal incisions, but the hysterectomy is still performed vaginally.
    • The CPT® codes for vaginal hysterectomy (58260-58294) should be used for vNOTES.

Identifying Laparoscopic Procedures

• • Clues in the operative notes to identify laparoscopic procedures:
    • Use of laparoscopic or robotic supplies (e.g., Veress needle, trocar, da Vinci® system)
    • Multiple small incisions vs. a single large incision
    • Insufflation and desufflation of the abdomen
  • If a laparoscopic procedure is converted to an open procedure, the open procedure should be coded.

Case Example: Conversion to Open Surgery

• • A patient undergoing a robotic-assisted total laparoscopic hysterectomy with bilateral salpingectomy had a large uterus (874 grams). Due to size, the procedure was converted to a mini laparotomy for specimen removal.
  • Correct code: 58150 Total abdominal hysterectomy, as the surgery was converted to open.
• Hysterectomy Post-Delivery
  • Following Cesarean Delivery:
    • Use CPT® +59525 for subtotal or total hysterectomy if performed through the same incision as a cesarean.
    • Use CPT® +58611 for fallopian tube ligation or transection performed at the same time.
  • Following Vaginal Delivery:
    • Use the appropriate hysterectomy code (e.g., 58150) depending on the procedure’s approach and extent.

Coding for Trachelectomy

• • Open Trachelectomy: CPT® 57530 (amputation of the cervix).
  • Radical Trachelectomy: CPT® 57531 (with pelvic lymphadenectomy).
  • Laparoscopic Trachelectomy: No specific CPT® code, use:
    • 58578 Unlisted laparoscopic procedure, uterus, or
    • 58661 Laparoscopy with adnexal removal, adding modifier 22 if additional work is performed.

Final Notes

• • Always consult the operative report for details on the surgical approach and any additional procedures.
  • Clarify any missing documentation, such as the uterus weight, with the provider to ensure correct coding.