Common Surgical Procedures Gyn/Oncology

Common Surgical Procedures Gyn/Oncology

Malignancy / Description / Codes / wRVU / Global
Days / Comments
Cervical / Typical Open
Cone biopsy / 57520 / 4.11 / 090
Leep conization / 57522 / 3.67 / 090
Colposcopy/Leep / 57461 / 3.43 / 000
TAH +/- BSO / 58150 / 17.31 / 090
Radical hysterectomy
+/- BSO
Pelvic lymphadenectomy (Total, bilateral)
Para-aortic sampling / 58210 / 30.91 / 090 / Includes excision of parametria and ureteral dissection.
Can be used for TAH PLND
Radical trachelectomy
+/-BSO
Pelvic lymphadenectomy
(Total bilateral)
Para-aortic sampling / 57531 / 29.95 / 090
Cervical / Less Common Open
Radical vaginal hyst (Schauta) / 58285 / 23.38 / 090 / Includes excision of parametria and ureteral dissection
Modifier 52 fertility sparing +/- nodes
Radical vaginectomy
Partial removal wall / 57107 / 24.56 / 090 / Includes removal of paravaginal tissue
Partial Vaginectomy use 57106
Radical vaginectomy
Partial removal wall
Pelvic lymphadenectomy
(Total bilateral)
Para-aortic sampling / 57109 / 28.40 / 090 / Includes removal of paravaginal tissue
Radical vaginectomy
Complete removal wall / 57111 / 28.40 / 090 / Includes removal of paravaginal tissue
Complete vaginectomy 57110
Radical vaginectomy
Complete removal wall
Pelvic lymphadenectomy
(Total bilateral)
Para-aortic sampling / 57112 / 30.52 / 090 / Includes removal of paravaginal tissue
Pelvic lymphadenectomy
External iliac
Hypogastric/Obturator / 38770 / 14.06 / 090 / Use modifier 50 for bilateral procedure
Cervical / Laparoscopic
Radical hysterectomy
+/- BSO
Pelvic lymphadenectomy
(Total bilateral)
Para-aortic sampling / 58548 / 31.63 / 090
Pelvic lymphadenectomy
(Total bilateral) / 38571 / 14.76 / 010
Pelvic lymphadenectomy
(Total bilateral)
Para-aortic sampling / 38572 / 16.94 / 010
Malignancy / Description / Codes / wRVU / Global
Days / Comments
Endometrial / Open
TAH +/- BSO / 58150 / 17.31 / 090
TAH +/- BSO
P&P sampling / 58200 / 23.10 / 090
Radical hysterectomy
+/- BSO
Pelvic lymphadenectomy
(Total, bilateral)
Para-aortic sampling / 58210 / 30.91 / 090 / Includes excision of parametria and ureteral dissection.
Can be used for TAH PLND
TAH/BSO
Omentectomy
Debulking / 58953 / 34.13 / 090
TAH/BSO
Omentectomy
Debulking
Pelvic lymphadenectomy
Limited para-aortic lymphadenectomy / 58954 / 37.13 / 090
TAH/BSO
Omentectomy / 58956 / 22.80 / 090 / Code indicates used for malignancy only
TAH/BSO
P&P nodes
Omentectomy / 58210-22 / 30.91 / 090 / Increase fee to reflect use of modifier 22
Endometrial / Laparoscopic
LAVH <250gms / 58550 / 15.10 / 090
LAVH BSO / 58552 / 16.91 / 090
LAVH >250gms / 58553 / 20.06 / 090
LAVH BSO / 58554 / 23.11 / 090
TLH <250gms / 58570 / 15.88 / 090
TLH BSO / 58571 / 17.69 / 090
TLH >250gms / 58572 / 20.09 / 090
TLH BSO / 58573 / 23.11 / 090
Endometrial / Laparoscopic Nodes
Retroperitoneal sampling / 38570 / 9.34 / 010 / Single or multiple nodes
Pelvic lymphadenectomy
(Total bilateral) / 38571 / 14.76 / 010
Pelvic lymphadenectomy
(Total bilateral)
Para-aortic sampling / 38572 / 16.94 / 010 / Single or multiple nodes
Malignancy / Description / Codes / wRVU / Global
Days / Comments
Ovarian/
Peritoneal / Open
Oophorectomy
P&P node sampling
Peritoneal biopsies/washings
+/- salpingectomy
+/- omentectomy / 58943 / 19.52 / 090 / Partial or total oophorectomy, unilateral or bilateral
Specific for ovarian, tubal, or primary peritoneal malignancy
BSO
Omentectomy / 58950 / 18.37 / 090 / Initial resection of ovarian, tubal, or primary peritoneal malignancy
TAH/BSO
Omentectomy
Pelvic lymphadenectomy
Limited para-aortic lymphadenectomy / 58951 / 24.26 / 090 / Initial resection of ovarian, tubal, or primary peritoneal malignancy
BSO
Omentectomy
Debulking (radical dissection) / 58952 / 27.29 / 090 / Initial resection of ovarian, tubal, or primary peritoneal malignancy
Radical excision/destruction intra-abdominal or retroperitoneal tumors
TAH/BSO,
Omentectomy
Debulking (radical dissection) / 58953 / 34.13 / 090 / All sites
TAH/BSO
Omentectomy
Debulking (radical dissection)
Pelvic lymphadenectomy
Limited para-aortic lymphadenectomy / 58954 / 37.13 / 090 / All sites
TAH/BSO
Omentectomy / 58956 / 22.80 / 090 / All sites
Debulking
+/- omentectomy / 58957 / 26.22 / 090 / Recurrent gyn resection
Debulking
+/- omentectomy
Pelvic lymphadenectomy
Limited para-aortic lymphadenectomy / 58958 / 29.22 / 090 / Recurrent gyn resection
Staging (second look)
+/- omentectomy
Biopsy abd/pelvic
Pelvic and limited para-aortic lymphadenectomy / 58960 / 15.79 / 090 / Specific for ovarian, tubal, or primary peritoneal malignancy
Ovarian/
Peritoneal / Laparoscopic
Second look with biopsy
With nodes / 49321
38572 / 5.44
16.94 / 010
010 / No codes for debulking: unlisted
Staging / 49320
38572 / 5.14
16.94 / 010
010 / 22 modifier as appropriate
Malignancy / Description / Code / wRVU / Global
Days / Comments
Vaginal / Open
Vaginectomy, partial / 57106 / 7.50 / 090
Vaginectomy, partial
Removal of paravaginal tissue (radical) / 57107 / 24.56 / 090
Vaginectomy, partial
Removal of paravaginal tissue (radical)
Bilateral total pelvic lymphadenectomy
Para-aortic lymph node sampling / 57109 / 28.40 / 090
Vaginectomy, complete / 57110 / 15.48 / 090
Vaginectomy, complete
Removal of paravaginal tissue (radical) / 57111 / 28.40 / 090
Vaginectomy, complete
Removal of paravaginal tissue (radical)
Bilateral total pelvic lymphadenectomy
Para-aortic lymph node sampling / 57112 / 30.52 / 090
Biopsy of vaginal mucosa, simple / 57100 / 1.20 / 000
Biopsy of vaginal mucosa, extensive / 57105 / 1.74 / 010 / Requires sutures
Includes cysts
Destruction of lesion(s), simple / 57061 / 1.30 / 010
Destruction of lesion(s), extensive / 57065 / 2.66 / 010
Malignancy / Description / Code / wRVU / Global
Days / Comments
Vulvar / Simple: removal of skin and superficial subcutaneous tissue
Radical: removal of skin and deep subcutaneous tissue
Partial: Removal of <80% vulvar area
Complete: Removal of >80% vulvar area
Vulvar / Open
Vulvectomy, simple, partial / 56620 / 7.53 / 090
Vulvectomy, simple, complete / 56625 / 9.68 / 090
Vulvectomy, radical, partial / 56630 / 14.80 / 090
Vulvectomy, radical, partial
Unilateral inguinofemoral lymphadenectomy / 56631 / 18.99 / 090
Vulvectomy, radical, partial
Bilateral inguinofemoral lymphadenectomy / 56632 / 21.86 / 090
Vulvectomy, radical, complete / 56633 / 19.62 / 090
Vulvectomy, radical, complete
Unilateral inguinofemoral lymphadenectomy / 56634 / 20.66 / 090
Vulvectomy, radical, complete
Bilateral inguinofemoral lymphadenectomy / 56637 / 24.75 / 090
Vulvectomy, radical, complete
Inguinofemoral lymphadenectomy
Iliac lymphadenectomy
Pelvic lymphadenectomy / 56640 / 24.78 / 090
Biopsy vulva or perineum; 1 lesion / 56605 / 1.10 / 000
Biopsy of each additional lesion vulva or perineum / +56606 / 0.55 / ZZZ / Add on code. Use with 56605
Excision benign lesion of genitalia / 11420-11426 / Varies
by
code / Varies
by
code / Based on excised diameter.
Use if skin not excised.
Excision malignant lesion of genitalia / 11620-11626 / Varies
by
code / Varies
by
code / Based on excised diameter.
Use if skin not excised.
Intermediate repair code genitalia / 12041-12047 / Varies
by
code / Varies
by
code / Use in conjunction with 11420-11426 and 11620-11626 if layered closure required
Malignancy / Description / Code / wRVU / Global
Days / Comments
Bowel Procedures / Open
Partial Colectomy / Partial colectomy with anastomosis / 44140 / 22.59 / 090
Partial colectomy
Skin level cecostomy or colostomy / 44141 / 29.91 / 090
Partial colectomy
End colostomy and closure of distal segment (Hartmann type procedure) / 44143 / 27.79 / 090
Partial colectomy
Resection, with colostomy or ileostomy
Creation of mucofistula / 44144 / 29.91 / 090
Partial colectomy
Coloproctostomy (low pelvic anastomosis) / 44145 / 28.58 / 090
Partial colectomy
Coloproctostomy (low pelvic anastomosis)
Colostomy / 44146 / 35.30 / 090
Partial colectomy
Abdominal and Transanal approach / 44147 / 33.69 / 090
Mobilization (take-down) of splenic flexure / +44139 / 2.23 / ZZZ / Add on code. Use with 44140-44147
Colectomy, partial
Removal of terminal ileum with ileocolostomy / 44160 / 20.89 / 090
Total Colectomy / Colectomy, total
Ileostomy or ileoproctostomy / 44150 / 30.18 / 090
Total colectomy
Continent ileostomy / 44151 / 34.92 / 090
Total colectomy
Proctectomy
Ileostomy / 44155 / 34.42 / 090
Total colectomy
Proctectomy
Continent ileostomy / 44156 / 37.42 / 090
Total colectomy
Proctectomy
Ileoanal anastomosis, / 44157 / 35.70 / 090 / Includes loop ileostomy, and rectal mucosectomy, when performed
Total colectomy
Proctectomy
Ileoanal anastomosis
Creation of ileal reservoir (S or J) / 44158 / 36.70 / 090 / Includes loop ileostomy, and rectal mucosectomy, when performed
Enterectomy / Small bowel resection / 44120 / 20.82 / 090
Each additional resection and anastomosis / +44121 / 4.44 / ZZZ / Add-on code. Use with 44120
Small bowel resection
Enterostomy / 44125 / 20.03 / 090
Malignancy / Description / Code / wRVU / Global
Days / Comments
Bowel Procedures / Laparoscopic
Laparoscopic enterectomy
Single resection of small intestine
Anastomosis / 44202 / 23.39 / 090
Each additional small intestine resection and anastomosis / +44203 / 4.44 / ZZZ / Add-on code. Use with 44202
Laparoscopic partial colectomy Anastomosis / 44204 / 26.42 / 090
Laparoscopic partial colectomy
Removal of terminal ileum
Ileocolostomy / 44205 / 22.95 / 090
Laparoscopic partial colectomy
End colostomy and closure of distal segment (Hartmann type procedure) / 44206 / 29.79 / 090
Laparoscopic partial colectomy
Coloproctostomy (low pelvic anastomosis) / 44207 / 31.92 / 090
Laparoscopic partial colectomy
Coloproctostomy (low pelvic anastomosis)
Colostomy / 44208 / 33.99 / 090
Laparoscopy mobilization (take-down) of splenic flexure / +44213 / 3.50 / ZZZ / Add-on code. Use with 44204-44208
Malignancy / Description / Code / wRVU / Global
Days / Comments
Other Procedures / Open
Exploratory laparotomy / 49000 / 12.54 / 090 / Includes biopsies if performed
Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less / 49203 / 20.13 / 090 / Codes appropriate when primary organs have been removed.
If ovarian tumor, use appropriate ovarian tumor or BSO code.
Largest tumor 5.1-10.0 cm diameter / 49204 / 26.13 / 090
Largest tumor greater than 10.0 cm diameter / 49205 / 30.13 / 090
Appendectomy; / 44950 / 10.60 / 090
For indicated purpose at time of major procedure / +44955 / 1.53 / ZZZ / Add-on code. Report in addition to primary surgical procedure
Enterolysis / 44005 / 18.46 / 090 / Designated as (Separate procedure). Generally not reported in addition to other surgical codes. If enterolysis is extensive, may report with 59 modifier
Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis / 50715 / 20.64 / 090 / Must have diagnosis of retroperitoneal fibrosis to report. Typically, ureterolysis is included in major surgical procedure.
Other Procedures / Laparoscopy
Diagnostic laparoscopy / 49320 / 5.14 / 010
Laparoscopy with biopsy / 49321 / 5.44 / 010 / Use for ovarian biopsy
Laparoscopy with aspiration of cavity or cyst (single or multiple) / 49322 / 6.01 / 010 / Use for aspiration of ovarian cyst
Laparoscopic appendectomy / 44970 / 9.45 / 090 / There is not an add-on code for laparoscopic appendectomy
Laparoscopic enterolysis / 44180 / 15.27 / 090 / Designated as (Separate procedure). Generally not reported in addition to other surgical codes. If enterolysis is extensive, may report with 59 modifier

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Revised January 2013