Coding Vaginal Hysterectomy – Be Familiar with the CPT Codes

by | Oct 30, 2018 | Blog, Medical Coding

Hysterectomy is the second most frequently performed surgical procedures in the United States with reports suggesting about 650,000 procedures being performed each year. The surgical procedure is done to remove a woman’s uterus or womb. After this procedure, a woman may no longer have menstrual periods and can’t become pregnant. In some cases, the surgery also removes the ovaries and fallopian tubes. If you have both ovaries taken out, you will enter menopause. Surgeons can perform hysterectomy vaginally, abdominally or laparoscopically, with each option depending on the person’s specific condition. Vaginal hysterectomy is a surgical procedure to remove the uterus through the vagina. When compared to other types, hysterectomy through the vagina is minimally invasive, so recovery is normally shorter and easier. Vaginal hysterectomy is a common procedure in gynecology practice, and medical coding for the same is a real challenge due to many code choices. Along with the specific surgical approach and the extent (whether it’s total or partial) of the hysterectomy, accounting for related performed procedures is vital to code selection. OB-GYN (obstetrician-gynecologist) or other general surgeons performing vaginal hysterectomy should correctly document the procedures performed in the patients’ medical records. Outsourcing medical billing and coding tasks to a reliable medical billing and coding company can help physicians simplify their documentation process.

Vaginal Hysterectomy

As part of vaginal hysterectomy, the surgeon detaches the uterus from the ovaries, fallopian tubes and upper vagina, as well as from the blood vessels and connective tissue that support it. The uterus is finally removed through the vagina. Depending on the patient’s condition, the procedure can last anywhere between 60 – 90 minutes.

Why Is Vaginal Hysterectomy Done?

The American College of Obstetricians and Gynecologists (ACOG) recommends vaginal hysterectomy for benign disorders where possible. Surgeons generally conduct this procedure to treat different types of gynecologic problems, including –

  • Small uterine fibroids or benign growth in the uterus wall
  • Endometriosis – when the tissue lining your uterus (endometrium) grows outside of the uterus
  • Uterine prolapse when the uterus has slipped out of place
  • Heavy or irregular menstrual bleeding that does not respond to other treatments
  • Gynecologic cancer (involving cancer of the uterus, cervix, endometrium or ovaries)
  • Chronic pelvic pain

Although any surgery has its own set of risk elements, some risk factors that accompany vaginal hysterectomy are – heavy bleeding, infection, blood clots in the legs or lungs, infections and injury to other pelvic and abdominal organs. Surgical risks are quite higher in women who are obese or who have high blood pressure.

The Procedure

For those who are undergoing vaginal hysterectomy, regional anesthesia will be preferred as it will block the sensation in the lower half of your body.

Patients need to lie in a position similar to that for a Pap test. As part of the procedure, the surgeon will make an incision inside your vagina to get to the uterus. Using long instruments, your surgeon clamps the uterine blood vessels and separates the uterus from the connective tissue, ovaries and fallopian tubes. Uterus is removed through the vaginal opening, and absorbable stitches are used to control any bleeding inside the pelvis.

Applicable CPT Codes

Obstetrics and Gynecology medical billing and coding is challenging, as it involves numerous rules related to reporting the procedure accurately. Obstetrician-gynecologists or other surgeons performing vaginal hysterectomy must use the relevant CPT codes to bill for the procedure. The CPT codes for vaginal hysterectomy include –

  • 58260 – Vaginal hysterectomy, for uterus 250 g or less
  • 58262 – Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)
  • 58263 – Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele
  • 58267 – Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control
  • 58270 – Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele
  • 58275 – Vaginal hysterectomy, with total or partial vaginectomy
  • 58280 – Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele
  • 58285 – Vaginal hysterectomy, radical (Schauta type operation)
  • 58290 – Vaginal hysterectomy, for uterus greater than 250 g
  • 58291 – Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
  • 58292 – Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele
  • 58293 – Vaginal hysterectomy, for uterus greater than 250 g; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control
  • 58294 – Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele

Recovery after the Procedure

As soon as the hysterectomy procedure is complete, patients will be shifted to a recovery room and their heart rate, blood pressure, level of pain and feelings of nausea will be closely monitored. Medications to reduce pain and prevent infections will be directly administered. The average period of hospital stay after the procedure is generally two days or possibly longer.

In the first few weeks after a vaginal hysterectomy, it is normal to have bleeding (similar to a light menstrual period) that comes and goes but decreases over time. Patients may also experience mild pain, discomfort in the lower belly and bloating or constipation as the bowel has temporarily slowed down.

Although the procedure is less invasive than other types, it will still take a considerable amount of time for patients to fully recover and get back to their normal activities. The time of recovery will differ from one individual to another and may depend on the type of procedure performed. In most cases, a full recovery may take up to 2-3 weeks. Therefore, patients need to limit their activities for a few weeks and follow the post-operative instructions carefully. There are several things to avoid for a smooth recovery –

  • Avoid putting anything in the vagina for at least 4 to 6 weeks
  • Avoid strenuous tasks and heavy lifting during the first 6 weeks
  • Avoid vaginal intercourse until six weeks after surgery
  • Avoid swimming until the vaginal stitches have healed completely

Following the above instructions carefully can lead to quick healing and reduced risk of complications. Taking adequate amount of rest, consuming a high-fiber diet and attending regular follow-up visits is important for a healthy surgical recovery.

Medical billing and coding requires a high level of knowledge regarding appropriate coding modifiers and payer-specific medical billing are essential for correct and on-time reimbursement. With all the complexities involved, the support of a reliable and experienced medical coding service provider can be useful for reporting vaginal hysterectomy procedure correctly.

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