January 16, 2012

Coding for Hysterectomy
For The Record
Vol. 24 No. 1 P. 28

Hysterectomy is the surgical removal of the uterus. It is one of the most common surgical procedures among women and is typically considered only after all other treatment options have been tried and failed.

Conditions Requiring Hysterectomy
A hysterectomy may be performed to treat any one of the following conditions:

• Uterine fibroids (ICD-9-CM category 218): benign tumors of the uterus, which are also called leiomyoma, fibromyoma, or myoma, and may cause persistent bleeding, anemia, pelvic pain, pain during intercourse, and bladder pressure.

• Uterine prolapse (category 618): downward displacement of the uterus into the vaginal canal due to the weakening of supporting tissues.

• Cancer of the uterus (179 or category 182), cervix (category 180), or ovary (183.0).

• Endometriosis (617.0): also called adenomyosis, uterine-lining tissue that grows outside the uterus that causes pain or bleeding.

• Functional vaginal bleeding (626.8): heavy, irregular, or prolonged menstrual periods.

• Chronic pelvic pain (625.9): caused by pain arising from the uterus.

Types of Hysterectomy
Depending on the condition necessitating the hysterectomy and the extent of the condition, the surgeon may choose to remove all or only a portion of the uterus. The following are different variations of a hysterectomy that may be performed:

• Subtotal or partial hysterectomy, also called supracervical or supravaginal, is the excision of the upper part of the uterus, leaving the cervix in place.

• Total hysterectomy removes the entire uterus and cervix.

• Radical hysterectomy is the removal of the entire uterus, surrounding tissue, the cervix, and the top part of the vagina.

Hysterectomy Approach
Surgical approaches for hysterectomy include the following (see table below for ICD-9-CM code assignment):

• Abdominal: An incision is made in the lower abdomen, and the uterus is removed through this incision. This open procedure is the most common approach for hysterectomy.

• Vaginal: An incision is made in the vagina, and the uterus is removed through the vagina.

• Laparoscopic: The hysterectomy is performed using a laparoscope and surgical tools inserted through the several small cuts in the body. The surgeon views the operation on a video screen.

• Laparoscopic-assisted vaginal: Using laparoscopic surgical tools, the uterus is removed through an incision in the vagina.

• Robot-assisted laparoscopic: Similar to the laparoscopic hysterectomy, the surgeon controls a robotic system of surgical tools outside the body.

If the procedure was performed with robotic assistance, assign one of these codes as a secondary procedure sequenced after the appropriate hysterectomy code: 17.41, Open robotic assisted procedure; or 17.42, Laparoscopic robotic assisted procedure.

Accompanying Procedures
Other procedures that may be performed with the hysterectomy include the following:

• Salpingo-oophorectomy: removal of fallopian tubes and ovaries. Specific code assignment will depend on whether the procedure was unilateral, bilateral, open, or laparoscopic and if the tubes and ovaries were removed or if only the tubes or ovaries were excised.

• Repair of cystocele (70.51): repair of bladder prolapsed.

• Repair of rectocele (70.52): repair of bowel/rectal prolapsed.

• Combined repair of cystocele and rectocele (70.50).

• Colpopexy (70.77): suture of the vagina to the abdominal wall.

• Marshall-Marchetti-Krantz operation (59.5)

• Lymphadenectomy (code assignment will depend which lymph nodes were taken and the extent)

Alternatives to Hysterectomy
The following are potential alternatives to a hysterectomy:

• Endometrial ablation for abnormal uterine bleeding (68.23): laser surgery, which may be done through a hysteroscope, to remove fibroids. A dilation and curettage for endometrial ablation is also classified to code 68.23.

• Laser therapy of uterus for endometriosis and precancerous lesions of cervix (68.23)

• Cryosurgery of endometrial tissue (68.23)

• Myomectomy for uterine fibroids (68.29)

• Uterine fibroid embolization (UFE): a nonsurgical, minimally invasive procedure that, over time, will shrink the fibroids by cutting off the blood supply, with the possibility they will eventually disappear.

 UFE may be performed with coils and is classified to code 68.24. The procedure may be performed by injecting other particles into the arteries, such as gelatin sponge, gelfoam, microspheres, polyvinyl alcohol, spherical embolics, or other particulate agent. Assign code 68.25 if the UFE is done without coils.

Coding and sequencing for hysterectomy are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.

 

ICD-10-PCS Coding for Hysterectomy
When coding the hysterectomy procedure in ICD-10-PCS, it is imperative that the operative report identify each body part removed (eg, uterus, cervix, fallopian tubes, ovaries). If a total hysterectomy is performed, the root operation will be resection, which is defined as the cutting out or off, without replacement, all of a body part. If a partial or subtotal hysterectomy is performed, the root operation will be excision, which is the cutting out or off, without replacement, a portion of a body part. The approach may include one of the following:

• Open: cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure.

• Percutaneous endoscopic: entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure.

• Via natural or artificial opening: entry of instrumentation through a natural or artificial external opening to reach the site of the procedure.

• Via natural or artificial opening endoscopic: entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure.

• Via natural or artificial opening with percutaneous endoscopic assistance.

Assign additional codes for the other body parts removed. Removal of ovaries and tubes must be designated as right, left, or bilateral.

If lymph nodes were removed, documentation must specify which lymph nodes, such as aortic or pelvic, and the approach, such as open, percutaneous, or percutaneous endoscopic. The root operation will be resection. However, if all the lymph nodes in a chain are not removed, then the root operation of excision would be used.

— AH

 

Hysterectomy Approach	Subtotal or Partial	Total	Radical
Laparoscopic Abdominal	68.31	68.41	68.61
Laparoscopic Vaginal	68.51	68.51	68.71
Open Abdominal	68.39	68.49	68.69
Open Vaginal	68.59	68.59	68.79