The patient is a 56 year-old female who is admitted for a prophylactic robotic-assisted laparoscopic total abdominal hysterectomy and bilateral laparoscopic salpingo-oophorectomy due to a high familial risk for ovarian cancer. A malignancy is subsequently found in the uterus. Coding Clinic, Fourth Quarter 1994, pages 44-45, addressed prophylactic organ removal. However, it did not address coding if a malignancy is found. Should a code for the malignancy be assigned as the principal diagnosis? Or, should a code from category V50.4 be assigned as principal diagnosis?
Assign code V50.42, Prophylactic organ removal, Ovary, as the principal diagnosis, since this was the reason for admission. Codes 182.0, Malignant neoplasm of corpus uteri, except isthmus, V50.49, Prophylactic organ removal, other, and V16.41, Family history of malignant neoplasm, Ovary, should be assigned as additional diagnoses. For the procedures, assign code 68.41, Laparoscopic total abdominal hysterectomy, code 65.63, Laparoscopic removal of both ovaries and tubes at the same operative episode, and code 17.42, Laparoscopic robotic assisted procedure.