Hysterectomy is the surgical removal that the uterus. It is one of the most usual surgical procedures among women and also is generally considered only after all various other treatment choices have to be tried and failed.
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Conditions requiring Hysterectomy A hysterectomy might be performed to treat any type of one the the following conditions:
• Uterine fibroids (ICD-9-CM category 218): light tumors of the uterus, i beg your pardon are likewise called leiomyoma, fibromyoma, or myoma, and may reason persistent bleeding, anemia, pelvic pain, pain during intercourse, and bladder pressure.
• Uterine prolapse (category 618): downward displacement that the uterus into the quality canal because of the weakening of supporting tissues.
• Cancer that the uterus (179 or group 182), cervix (category 180), or ovary (183.0).
• Endometriosis (617.0): likewise called adenomyosis, uterine-lining tissue that grows outside the uterus that reasons pain or bleeding.
• functional vaginal bleeding (626.8): heavy, irregular, or prolonged menstrual periods.
• Chronic pelvic ache (625.9): led to by pain occurring from the uterus.
Types of Hysterectomy depending on the problem necessitating the hysterectomy and the extent of the condition, the operated doctor may pick to remove all or only a portion of the uterus. The complying with are different variations the 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.
• complete hysterectomy gets rid of the entire uterus and cervix.
• Radical hysterectomy is the removed of the whole uterus, bordering tissue, the cervix, and the top part of the vagina.
Hysterectomy Approach Surgical approaches for hysterectomy incorporate the adhering to (see table below for ICD-9-CM code assignment):
• Abdominal: An scratch is made in the lower abdomen, and also the uterus is gotten rid of through this incision. This open procedure is the most common technique for hysterectomy.
• Vaginal: An scratch is make in the vagina, and the uterus is gotten rid of through the vagina.
• Laparoscopic: The hysterectomy is performed utilizing a laparoscope and also surgical tools placed through the several tiny cuts in the body. The surgeon see the procedure on a video screen.
• Laparoscopic-assisted vaginal: utilizing laparoscopic operation tools, the uterus is gotten rid of through an incision in the vagina.
• Robot-assisted laparoscopic: similar to the laparoscopic hysterectomy, the operated doctor controls a robotic system of operation tools external the body.
If the procedure was performed through robotic assistance, assign one of these codes as a second procedure sequenced after the appropriate hysterectomy code: 17.41, open robotic helped procedure; or 17.42, Laparoscopic robotic aided procedure.
Accompanying Procedures Other actions that may be performed v the hysterectomy encompass the following:
• Salpingo-oophorectomy: removed of fallopian tubes and also ovaries. Particular code assignment will count on even if it is the procedure was unilateral, bilateral, open, or laparoscopic and also if the tubes and also ovaries were removed or if only the pipe or ovaries to be excised.
• fix of cystocele (70.51): repair of bladder prolapsed.
• repair of rectocele (70.52): repair of bowel/rectal prolapsed.
• combined repair that cystocele and also rectocele (70.50).
• Colpopexy (70.77): suture that the vagina come the ab wall.
• Marshall-Marchetti-Krantz procedure (59.5)
• Lymphadenectomy (code assignment will count which lymph nodes to be taken and also the extent)
Alternatives to Hysterectomy The following are potential alternatives to a hysterectomy:
• Endometrial ablation because that abnormal uterine bleeding (68.23): laser surgery, which may be done through a hysteroscope, to eliminate fibroids. A dilation and curettage for endometrial ablation is additionally classified to code 68.23.
• Laser therapy of uterus because that endometriosis and also precancerous lesions the cervix (68.23)
• Cryosurgery the 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 through cutting turn off the blood supply, through the possibility they will eventually disappear.
UFE may be performed v coils and is classified to password 68.24. The procedure might be performed by injecting other particles right into the arteries, such together gelatin sponge, gelfoam, microspheres, polyvinyl alcohol, spherical embolics, or various other particulate agent. Assign code 68.25 if the UFE is excellent without coils.
Coding and also sequencing for hysterectomy space dependent on the doctor documentation in the medical record and also application of the main Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and also American clinical Association CPT Assistant references to ensure complete and accurate coding.
— This info was ready by Audrey Howard, RHIA, the 3M Consulting Services. 3M Consulting solutions is a company of 3M health Information Systems, a caterer of coding and also classification systems to an ext than 5,000 healthcare providers. The firm and its representatives perform not assume any type of responsibility because that reimbursement decisions or cases denials make by service providers or payers as the an outcome of the misuse of this coding information. Much more information around 3M health Information systems is easily accessible at www.3mhis.com or by calling 800-367-2447.
ICD-10-PCS Coding because that Hysterectomy as soon as coding the hysterectomy procedure in ICD-10-PCS, the is imperative that the operative report identify each body component removed (eg, uterus, cervix, fallopian tubes, ovaries). If a complete hysterectomy is performed, the root operation will it is in resection, which is characterized as the cutting the end or off, there is no replacement, all of a body part. If a partial or subtotal hysterectomy is performed, the root procedure will it is in excision, which is the cutting the end or off, there is no replacement, a portion of a human body part. The method may incorporate one the the following:
• Open: cutting through the skin or mucous membrane and any other body layers essential to reveal the site of the procedure.
• Percutaneous endoscopic: entry, by puncture or boy incision, of instrumentation v the skin or mucous membrane and also any other body layers important to reach and visualize the site of the procedure.
• Via herbal or synthetic opening: entrance of instrumentation through a organic or artificial external opened to with the website of the procedure.
• Via organic or artificial opening endoscopic: entry of instrumentation through a herbal or fabricated external opening to reach and visualize the website of the procedure.
• Via natural or synthetic opening v percutaneous endoscopic assistance.
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Assign additional codes because that the other body parts removed. Remove of ovaries and also tubes should be designated together right, left, or bilateral.
If lymph nodes to be removed, documentation have to specify i m sorry lymph nodes, such together aortic or pelvic, and the approach, such as open, percutaneous, or percutaneous endoscopic. The root operation will it is in resection. However, if every the lymph nodes in a chain are not removed, climate the root operation of excision would certainly be used.