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Reporting uterine fibroid removals can be hard if you do not know the way the ob-gyn used to take care of the growth. Read this article and learn about each method of fibroid treatment, so you will be ready for whatever your ob-gyn chooses to carry out. Medical Coding Method 1: Count Hysterectomy As Most Common Procedure Hysterectomy is when the ob-gyn does away with the uterus completely. Even though this is the most common approach, it is used only when the fibroids are producing problems, for nstance abdominal pain or heavy bleeding. In case the uterus is not removed, there are chances are that the fibroids will reappear. When you execute the CPT lookup, the code assignment will hinge on on the type and extent of the hysterectomy. Coding example: As the patient is older than 50 years and has multiple fibroids, your ob-gyn carries out a total abdominal hysterectomy (58150, Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]). You would not code the fibroid removal distinctly if the ob-gyn is eliminating the uterus. Medical Coding Method 2: Hem in Your Hysteroscopy Choices Fibroids can also be treated using the hysteroscopic procedure. Hysteroscopic submucous resection gets rid of a portion of the protruding fibroid and preserves fertility. The procedure needs “the close monitoring of distention media, electrosurgical devices, along with a patient’s anatomy to circumvent perforating the uterus. Ob-gyns normally carry out this straightforward approach for intracavitary (submucosal) fibroids. Medical Coding Method 3: Master These Myomectomy Codes Myomectomy (58140-58146, 58545-58546) is one more choice for fibroid treatment. A myomectomy is the removal of uterine fibroids only, which preserves fertility. Example 1: The ob-gyn sees a 32-year-old patient who has never given birth to a child but wishes to. She goes through heavy menses with anemia. On examination, the physician finds a 15-cm uterus with manifold fibroids that distort the endometrium. As the patient wants to have children, she chooses to have a myomectomy, which the ob-gyn carries out by the means of an laparoscopic approach. The pathology report shows six intramural myomas. For this case, when you execute the CPT lookup, you must report 58545 (Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas). Medical Coding Method 4: Make Use of UAE Option You may see additional uterine fibroid embolization or uterine artery embolization (UAE) procedures. UAE is a nonsurgical, minimally invasive procedure that will shrink the fibroids by cutting off the blood supply. The ob-gyn inserts a catheter through an artery in the leg to the arteries in the uterus. The physician then inserts tiny particles of plastic or gelatin through the arteries to cease the blood flow inside the fibroids. Devoid of blood flow, the fibroids shrink or may even disappear over time. In case this method is followed, once you do the CPT lookup, you’ll report using 37210 (Uterine fibroid embolization [UFE, embolization of the uterine arteries to treat uterine fibroids, leiomyomata], percutaneous approach inclusive of vascular access, vessel selection, embolization, and all radiological supervision and interpretation, intraprocedural roadmapping, and image guidance necessary to complete the procedure).
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