AMA CPT® Assistant - 2017 Issue 2 (February)
Surgery: Female Genital System (Q&A) (February 2017)
February 2017 page 14b Surgery: Female Genital System Question: Would it be appropriate to report code 58674 for the ablation of uterine fibroids when there is no indication in the report of whether the procedure was performed using an open approach or whether it was performed laparoscopically? Answer: No. Code 58674, Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency, should only be reported when the procedure is performed laparoscopically. Be sure to consult the physician to verify the method before selecting a code to report. Surgery: Female Genital System (Q&A) (February 2017). CPT®...
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Article Overview
This short CPT Assistant Q&A explains a coding documentation issue for a female genital system surgery service and emphasizes the need to confirm the operative approach before assigning a code. It is useful for coders, billers, and clinicians who work with gynecologic procedures and documentation review.
Why This Topic Matters
Incomplete operative documentation can affect code selection for gynecologic surgery services, so this article helps readers understand the documentation point that must be verified before coding.
What You Will Learn
- What type of documentation detail must be confirmed for a gynecologic surgical procedure
- How CPT Assistant addresses coding when the operative approach is not specified
- Why physician clarification may be needed before reporting the service
- How documentation completeness affects review of female genital system surgery claims
Who Should Read This
- Medical coders
- Coding auditors
- Billing specialists
- Gynecology clinicians
- Revenue cycle staff
Codes Discussed
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