Best Practices for Correct Coding and Billing of 5 GYN Procedures

Here are best practices and guidelines for the correct coding and billing of five common gynecology procedures performed in ASCs.


1. Laparoscopy procedures
Here are the guidelines for locating the correct/most precise laparoscopy code.

  • Begin by looking up "laparoscopy" in your CPT manual's index.
  • Review the choices for the body area/organ/system the procedure examined or treated.
  • If you can’t find a code, look up the codes in the area of the CPT book for similar procedures done in an open fashion and see if there are any scope-applicable codes in that section. Look for codes which contain the descriptor suffix of "-oscopy." Do not code an "open" procedure code for a scope procedure.
  • If questions remain about correct coding, verify the code with the surgeon.
  • If no appropriate code can be located, use an unlisted laparoscopy code, file the claim as a paper claim and include the operative report with the claim.


If the patient has two unrelated laparoscopic procedures performed during the same operative session, both may be coded and billed. Check your CCI unbundling guidelines and if the procedures are unbundled but were performed in different areas, append a -59 modifier to the code that is unbundled.

Always remember that a diagnostic laparoscopy is included in a surgical laparoscopy and is not separately-billable.

2. Laparoscopic lysis of adhesions
Laparoscopy procedures often include lysis of (incidental) adhesions, which are not separately billable most of the time. The only time the lysis of adhesions procedure would be separately billable from other laparoscopic procedures (from which the lysis procedure is unbundled according to your CCI unbundling guidelines) would be if the lysis of adhesions procedure is performed for a different medical reason (with documented separate medical necessity, i.e., a different diagnosis) than the laparoscopy, the lysis procedure was performed in a different area than the other laparoscopy and the surgeon documents in the operative report that he/she spent a significant amount of time performing the lysis procedure.

If all of these circumstances are met, you can bill the lysis of adhesions procedure using the -59 modifier if it is unbundled from the other laparoscopy procedure.

3. Sling/TVT tape procedures
The sling operation for stress incontinence performed laparoscopically is coded 51992. Use the 57288 code if the procedure is performed as an open procedure. According to the AMA's CPT Assistant newsletter, CPT code 57288 describes the placement of fascia or other materials at the urethrovesical junction to encircle and suspend the urethra for treatment of stress incontinence. The ends of the sling are pulled toward the symphysis pubis and fastened to the rectus abdominus sheath. This procedure is for a combined anterior vaginal and abdominal approach.

In the laparoscopic procedure (code 51992), the endopelvic fascia is opened and a tunnel is dissected between the urethra and vaginal mucosa; sling material (cadaver or synthetic) is then passed through the tunnel and secured to Cowper's ligament bilaterally. If tape is used in the procedure, don’t forget to bill for the TVT tape — the C1771 HCPCS code can be used to bill for the sling supply to some payors, if the payor reimburses for implants. However, don’t use C-codes to bill implants to Medicare. Other possible codes to use instead (depending upon the payor) include L8699 or 99070.

4. Hysteroscopy procedures
Here are the guidelines for proper coding of hysteroscopy procedures.

  • Use code 58555 for a diagnostic hysteroscopy which would not be billable if a more extensive procedure is performed hysteroscopically. This code is designated as a “separate procedure” according to CPT guidelines.
  • When a hysteroscopy procedure includes a biopsy or polypectomy, and is performed with or without dilation and curettage, it is coded 58558.
  • When Essure, NovaSure, or similar implants are used for birth control, use code 58565 for the placement of these devices performed using a hysteroscope. Don’t forget to bill for the implant supply with codes L8699 or 99070.
  • Use code 58563 for an endometrial ablation procedure performed under hysteroscopic guidance (by endometrial resection, electrosurgical ablation, or thermoablation).
  • Use code 58353 for a thermal endometrial ablation procedure performed without hysteroscopic guidance.


5. Myomectomy/Fibroid excision procedures
Myomas are growths in the uterus, which are more commonly referred to as "fibroids" or "fibroid tumors," and they are the most common growth of the female genital tract. These tumors are benign and they are usually characterized as round, firm masses of the muscle wall of the uterus. Myomas are composed of smooth muscle and connective tissue, they can grow to be quite large, and are very common, as they affect as many as 30 percent of women. The growth of fibroid tumors is thought to be stimulated by estrogen. Common symptoms of fibroids include dysfunctional uterine bleeding, cramps, abdominal pain and pressure.

According to the CPT Assistant, there are several different types of uterine fibroids, which are classified based upon their location.

  • Intracavitary myomas are fibroids that are located inside of the uterus.
  • Submucous myomas are fibroids located partially in the uterine cavity and partially in the wall of the uterus.
  • Intramural myomas are fibroids usually located in the wall of the uterus. Their size can range from microscopic to larger than a grapefruit.
  • Pedunculated myomas are fibroids connected to the uterus by a stalk.


Coding of these procedures is based on the method of approach to remove the fibroids, the number of myomas removed and the total weight of the tissue removed.

▪ Use code 58140 for an open myomectomy procedure involving the excision of 1-4 intramural fibroid tumor(s) of the uterus with a total weight of 250 grams or less and/or removal of surface myomas, performed via an abdominal approach.

▪ Code 58145 for a myomectomy procedure involving the excision of 1-4 intramural fibroid tumor(s) of the uterus with a total weight of 250 grams or less and/or removal of surface myomas, performed via a vaginal approach.

▪ Code 58146 for an open myomectomy procedure involving the excision of 5 or more intramural fibroid tumor(s) of the uterus with a total weight greater than 250 grams, performed via an abdominal approach.

▪ Code 58545 is for a laparoscopic myomectomy with the excision of 1-4 intramural myomas with a total weight of 250 grams or less and/or the removal of surface myomas.

▪ Code 58546 is for a laparoscopic myomectomy excision of five or more intramural myomas with total weight greater than 250 grams.

Note: CPT codes are copyrighted by the AMA.

Ms. Ellis (sellis@ellismedical.com) is president of Ellis Medical Consulting (www.ellismedical.com), a healthcare consulting firm providing chart audits for coding and documentation issues, business office operational assessments, research of coverage issues, fee and coding revisions, litigation support, reimbursement research, coding/billing training, and the development and implementation of billing compliance programs for healthcare providers.

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