AHA Coding Clinic® for HCPCS - 2021 Issue 2; Ask the Editor

Laparoscopic hysterectomy coding

The Central Office has received several requests for clarification regarding the documentation requirement of the weight of the uterus when reporting CPT codes 58570, Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less;, and 58572, Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g;.The questions include whether the weight of the uterus can be taken from the pathology report or does the weight need to be documented in the operative report, and is there a default code when the weight is not documented. For example, is it appropriate to default to CPT code 58570 when there is no documentation of the weight of the uterus? ...

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