The Central Office on ICD-9-CM has recently received questions related to the differences in code assignment between total laparoscopic abdominal hysterectomy (TLH) procedures and laparoscopically assisted vaginal hysterectomy procedures (LAVH). Effective October 1, 2006, new procedure codes were created to distinguish between laparoscopic hysterectomies that utilize tiny incisions and traditional hysterectomies that require a large incision. For additional information on the other types of laparoscopic hysterectomy procedures, please refer to Coding Clinic, Fourth Quarter 2006, pages 130-134.
An important factor in assigning the correct ICD-9-CM hysterectomy procedure code is to determine what structures were detached and how they were detached based on the medical record documentation. The focus should be on the surgical technique or approach used for the detachment of those structures. Code assignment should not be based on the location of where the structures were physically removed from the patient’s body.
A total laparoscopic abdominal hysterectomy (TLH) involves detachment of the entire uterus and cervix from the surrounding supporting structures via the laparoscopic technique. The uterus is then removed through the vagina or abdomen. It may include bivalving, coring, or morcellating the excised tissues, as required. The procedure concludes with suturing of the vaginal cuff, removal of instruments and closure of the incisions.
The fact that the uterus is removed through the vagina does not indicate that the procedure performed was a laparoscopically assisted vaginal hysterectomy. For ICD-9-CM coding purposes, the key is that the structures were detached from surrounding structures or tissues laparoscopically via the abdomen.
A laparoscopically assisted vaginal hysterectomy involves use of the laparoscope to guide the procedure and visualize structures in addition to detaching the uterine body from the surrounding upper supporting structures (such as the infundibular pelvic and round ligaments), while the vaginal portion of the procedure involves an incision being made within the vagina to detach the cervix and uterus from the remaining supporting structures. The uterus is then removed through the vagina. The procedure concludes with the top part of the vagina being sutured, removal of instruments and closure of the incisions.
What is the procedure code assignment for a laparoscopic total abdominal hysterectomy when the uterus is pulled out through the vagina?
Assign code 68.41, Laparoscopic total abdominal hysterectomy. In a laparoscopic total hysterectomy, the uterine attachments are ligated and transected via a laparoscopic approach. The uterus and cervix are then removed intact through the vagina. Occasionally, the uterus is enlarged and cannot be taken out through the vagina. The surgeon can then morcellate the uterus and remove it via the port incision.
How should a laparoscopically assisted vaginal hysterectomy (LAVH) with bilateral laparoscopic salpingo-oophorectomy be coded?
Assign codes 68.51, Laparoscopically assisted vaginal hysterectomy; and 65.63, Laparoscopic removal of both ovaries and tubes at same operative episode. In contrast to the laparoscopic total abdominal hysterectomy, the LAVH involves making an incision within the vagina to detach the cervix and uterus and removing the organs through the vagina.