Hysterectomy Defined: Coding Advice for Gynecology-Driven ASCs
This article was written by Paul Cadorette, CPC, CPC-H, CPC-P, COSC, CASC, Director of Education for mdStrategies.
We have recently encountered varied opinions on how coding should be performed for laparoscopic total versus laparoscopic vaginal hysterectomies. The information below was taken from the American Congress of Obstetricians and Gynecologists website and is dated September 2012.
• Total laparoscopic hysterectomy (TLH) includes laparoscopically detaching the entire uterine cervix and body from the surrounding supporting structures and suturing the vaginal cuff. It includes bivalving, coring, or morcellating the excised tissues, as required. The uterus is then removed through the vagina or abdomen.
• Laparoscopic-assistedvaginal hysterectomy (LAVH) includes laparoscopically detaching the uterine body from the surrounding upper supporting structures. The vaginal portion of the procedure is then performed. The vaginal apex is entered and the cervix and uterus are detached from the remaining supporting structures. The uterus is then removed through the vagina.
• Laparoscopic supracervical hysterectomy (LSH) includes laparoscopically detaching the body of the uterus down to the uterine arteries. The uterine body is then separated from the cervix, hemostasis of the cervical stump is achieved, and the endocervical canal is coagulated. The uterine body is then abdominally removed by bivalving, coring, or morcellating, as required.
The confusion arises when a laparoscopic hysterectomy is initiated and then the contents are removed through the vagina. The documentation a coder should be looking at is how the structures are released. When the supporting structures are all taken down laparoscopically then it does not matter whether the contents are removed from the abdomen or vagina. This service would be coded as a laparoscopic total hysterectomy.
However, when only the upper supporting structures are taken down laparoscopically and then an incision is made in the vagina along with releasing the lower supporting structures through the vaginal incision then this service is considered a laparoscopic assisted vaginal hysterectomy (see example).
The operating surgeon then went to the console and with the robotic device completed the hysterectomy as follows: The round ligaments were cauterized and transected with monopolar scissors. The peritoneum overlying the psoas muscle was opened and the perirectal space entered. A space was created between the ureter and ovarian artery and vein. These were cauterized and ligated with the LigaSure device. This was completed in bilateral fashion. The medial leaf of the broad ligament was dissected at the level of the uterine vessels. The bladder flap was created. The uterine vessels were skeletonized and ligated then cauterized with the LigaSure device.
The posterior vaginal wall was then opened. We used the edge of the VCARE cap that had been placed on the cervix to do this. Once entered posteriorly a circumferential incision was completed during which the cardinal and uterosacral ligament were transected, the specimen was removed through the vagina.
Note that the procedure begins laparoscopically but then the lower supporting structures are transected through a vaginal incision and then structures are removed through the vagina constituting an LAVH.
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