It is critical that you inspect and remove all fragments and debris after morcellation to prevent iatrogenic multiple peritoneal parasitic myomas. First described in 2006,12 this unusual complication, leiomyomatosis peritonealis disseminate, has been reported with greater frequency as minimally invasive surgery and morcellation have become more common. This complication is thought to arise from small fragments left behind after morcellation of a uterus or myoma. Although spontaneous cases can occur, they are rare.
Place an adhesion barrier
Myomectomy can induce the formation of significant adhesions. For that reason, as the final step before fascial closure, we recommend that an adhesion barrier be placed over any hysterotomy sites. Although they are indicated and FDA-approved only for laparotomy, we typically place Interceed (Ethicon, Cornelia, Georgia) or Seprafilm (Genzyme, Framingham, Massachusetts) over hysterotomy sites.
CODING FOR ROBOT-ASSISTED MYOMECTOMY: ADDITIONAL REIMBURSEMENT MAY NOT BE FORTHCOMING
Robot-assisted surgery is an emerging technology. As such, many health insurance companies, the American Congress of Obstetricians and Gynecologists (ACOG), and Current Procedural Terminology (CPT) editorial staff have weighed in on it. In essence, many payers have indicated that they will not provide the physician with additional reimbursement for performing a surgical procedure using robotic assistance. That is not to say that all payers will rule out additional reimbursement, although most of the larger payers have indicated that additional reimbursement is not going to happen.
Both ACOG and CPT officials have indicated that robot-assisted surgical procedures should be reported using existing CPT codes, based on the procedure and the surgical approach used, rather than coding them as an unlisted procedure. These organizations also have indicated that use of the modifier –22 on the basic laparoscopic procedure would be inappropriate because robotic assistance does not represent an unusual procedure, based on the patient’s condition.
However, if there is a chance that you can gain additional reimbursement for robotic surgery, how can you inform the payer that it was performed? The only currently accepted way to do so is to report code S2900, Surgical techniques requiring use of robotic surgical system (list separately in addition to the code for the primary procedure), in addition to the basic code for the laparoscopic approach. Code S2900 was added by CPT to the national code set in 2005 at the request of Blue Cross/Blue Shield so that the payer could track the incidence of robotic surgery. Because it is not a “regular” CPT code, S2900 was never assigned a relative value, so it is up to the surgeon to set a surgical charge for use of the robot. In doing so, the surgeon must be able to provide supporting documentation as to why additional reimbursement is being requested and on what basis the charge was calculated.
Therefore, if a robot-assisted laparoscopic myomectomy is performed, the first CPT code listed on the claim should be 58545, Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas. An alternative would be code 58546, Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g.
Code S2900 then would be listed second. No modifiers (such as modifier –59 [distinct procedure] or –51 [multiple procedures]) should be added to S2900 because this code does not represent either a distinct or multiple surgical procedure.
—MELANIE WITT, RN, CPC, COBGC, MA
Ms. Witt is an independent coding and documentation consultant and former program manager, department of coding and nomenclature, American Congress of Obstetricians and Gynecologists.
CASE: RESOLVED
Because of the patient’s religious beliefs, minimal blood loss is an important goal for any surgery she undergoes. Consequently, you recommend robot-assisted laparoscopic myomectomy, and the operation is completed without complications.
TAKE-HOME MESSAGE
The success of minimally invasive myomectomy requires a careful preoperative work-up and thorough understanding of surgical dissection and suturing techniques. In combination with this knowledge, advanced surgical technology, such as robotics and barbed suture, can truly transform the way myomectomy is performed, providing both patients and physicians with additional options for the conservative management of symptomatic uterine fibroids.
KEY POINTS FOR SUCCESS WITH THE ROBOT
Select patients with care for robot-assisted laparoscopic myomectomy, and perform thorough preoperative assessment. When planning a surgical approach, keep in mind the patient’s uterine size and body habitus and the quantity, size, consistency, type, and location of fibroids.
Use preoperative magnetic resonance imaging to characterize and locate fibroids and differentiate adenomyosis from leiomyomas.
In patients with a uterus larger than approximately 14- to 16-weeks’ size, consider a supraumbilical camera port.
Although the 12-mm Xcel trocar comes in a variety of lengths (75–150 mm), use the 150-mm length for the camera port. Once the camera is docked high on the neck of the longer trocar, more space is created between the setup joints of the robotic arms, enabling greater range of motion and fewer instrument and arm collisions.
Whenever possible, perform a transverse hysterotomy, keeping the length of the incision as short as possible and minimizing use of thermal energy during enucleation of fibroids.
Do not enucleate myomas through force, but apply traction and position each fibroid in order to best delineate and pre-sent the leading edge between the myoma and the myometrium.
Use multilayer closure with reapproximation of the myometrium and serosal edges to achieve hemostasis and prevent hematoma.
Perform morcellation through a 5-mm laparoscope with the robot undocked, using the camera port site for morcellation.
Take the patient out of a steep Trendelenberg position and place her in minimal Trendelenberg during morcellation to optimize ergonomics and prevent fragments from falling into the upper
abdomen.
Inspect the abdomen and remove all fragments and debris after morcellation to help prevent leiomyomatosis peritonealis disseminate.