William H. Parker, MD Dr. Parker is Chair of Obstetrics and Gynecology at St. John’s Health Center in Santa Monica, Calif, and Clinical Professor of Obstetrics and Gynecology at UCLA School of Medicine in Los Angeles.
Either total or supracervical laparoscopic hysterectomy is feasible. Benefits include less postoperative pain, short hospital stay, and quick recovery. However, if a vaginal hysterectomy is feasible, there is no benefit to laparoscopic hysterectomy.36
What the data show
A prospective, randomized, multicenter study concluded that laparoscopic-assisted hysterectomy offered the benefits of less invasive surgery without increased risk.37 Eighty women whose uterus was between 280 g and 700 g were randomized to laparoscopic-assisted vaginal and abdominal hysterectomy. Estimated blood loss, postoperative day 1 hemoglobin level, pain, and hospital stay were all significantly better for the laparoscopic-assisted group. Complications in the abdominal hysterectomy group included one woman who had a cuff hematoma and who required transfusion; one who had bleeding requiring reoperation and transfusion; and five who had fever. The only complication in the laparoscopic group was postoperative fever in two women.
In experienced hands, the benefits of laparoscopic hysterectomy may extend to women who have large fibroids. A retrospective cohort study compared laparoscopic hysterectomy in 34 women who had a uterine weight greater than 500 g (range, 500 to 1,230 g) with 68 women whose uterus weighed less than 300 g.38 Operating time was significantly shorter in women with smaller uteri, but no difference was observed in complications, blood loss, hospital stay, or recovery, and no patient required conversion to laparotomy.
CASE 3 RESOLVED
S.L. underwent laparoscopic supracervical hysterectomy, which involved a 1-night hospital stay, and returned to work in 2 weeks. She is happy to be free of monthly bleeding and believes she made the right treatment decision.
GETTING REIMBURSED FOR TREATING UTERINE FIBROIDS
Just as there are multiple options for removing myomas, so are there multiple coding possibilities for this service. Note that some procedures require special documentation of the clinical circumstances to ensure correct payment and that other treatments may be considered investigational by payers.
Surgical removal of uterine fibroids can be accomplished vaginally (58145), abdominally (58140, 58146), hysteroscopically (58561), and laparoscopically (58545–58546). Except for the hysteroscopic approach, all require documentation of the number and weight of the fibroids, to ensure that payment reflects how much work was done. When five or more fibroids are removed, or when the combined weight of all fibroids removed exceeds 250 g, the CPT codes that represent these services will reimburse at a higher rate. When endometrial ablation is the treatment of choice, you must choose between hysteroscopic (58563) and nonhysteroscopic (58353) methods when selecting a code.
Insertion of the levonorgestrel-releasing intrauterine system (Mirena) requires that you report more than one code. Report insertion 58300 (S4981 for Blue Cross and Blue Shield carriers). Bill for the device itself with J7302, or with J7306 (the system and supplies).
Last, some payers consider uterine artery embolization investigational, even though it has its own CPT code (37210).—MELANIE WITT, RN, CPC-OGS, MA
