A hysterectomy is the surgical removal of the uterus. Most often, the procedure also includes the removal of the cervix. When a total hysterectomy is performed, both the uterus and cervix are removed. If only a partial hysterectomy is done, the cervix remains. This is also called a supracervical hysterectomy.
These procedures may be performed via a laparoscopic approach or through an open incision in the abdomen while others can be done vaginally.
Once a coding professional determines the methodology of the procedure, then other details are needed to complete the coding. For example, often the size of the uterus is a component of the code assignment. CPT determines the cut-off point to be 250 grams. Anything over that weight moves the code to another level. Once the size has been determined and the appropriate category found, then a coder must look to see if any other procedures were done concomitantly. Those other procedures could be removal of tubes and/or ovaries (which is the most common); the repair of enteroceles; partial vaginectomy; and lymph node procedures.
Now, let’s look at some examples. A patient has an open total abdominal hysterectomy for uterus 312 grams. The code would be 58150. If this was a laparoscopic procedure, the code changes to 58572, and if it was a vaginal procedure the code becomes 58290.
There are times when a hysterectomy is performed vaginally but with laparoscopic assistance. There is a specific section of codes (58550-58554) for those procedures.
Just a quick mention about radical hysterectomy procedures. These procedures are usually performed when there is a diagnosis of cancer. This procedure will entail the removal of the uterus, cervix, bilateral fallopian tubes and ovaries, lymph nodes, part of the vagina, and possibly other surrounding tissue. CPT has specific codes for radical hysterectomy procedures.
Now, light has been shed on coding for hysterectomies.
About the Author
Dianna Foley, RHIA, CHPS, CCS is
OHIMA's Coding Education Coordinator. Dianna has been an HIM
professional for 20 years. She progressed through the ranks of coder,
department supervisor, and department director, to her current role as a
coding consultant. She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.
