Deciding which myomectomy code you’ll report depends on three factors: the approach the ob-gyn uses, the number of myomas, and their weight. Here’s how to translate this information into the correct CPT code every time.
If your ob-gyn performs a hysterectomy, you won’t report the myomectomy separately.
When your ob-gyn performs a myomectomy, he is removing myomas or uterine fibroid tumors. Knowing what type they are will help you to determine your myomectomy code.
Myomas (also known as uterine fibromas) are the most common growth of the female genital tract. They are round, firm, benign masses of the muscular wall of the uterus and are composed of smooth muscle and connective tissue. You’ll see different types of uterine fibroids based on their location:
- Intracavitary myomas are fibroids inside the uterus.
- Submucous myomas are partially in the uterine cavity and partially in the wall of the uterus.
- Subserous myomas are on the outside wall of the uterus.
- Intramural myomas are in the wall of the uterus; their size can range from microscopic to larger than a grapefruit. These take a lot more effort to remove than a surface myoma.
- Pedunculated myomas are connected to the uterus by a stalk and are located inside the uterine cavity or on the outside surface.
Myomas often cause or are coincidental with abnormal uterine bleeding, pressure or pain. They are also one of the most common reasons women in their 30s or 40s have hysterectomies, says Peggy Stilley, CPC, COBGC, ACS-OB, director of auditing services at the American Academy of Professional Coders.
However, women who want to have children in the future or simply do not want their uterus removed look for alternative solutions. The following procedures describe abdominal, vaginal, and laparoscopic approaches.
First of all, look at the abdominal approach. When...
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