Monday, February 20, 2017

New Code 2017:  58674- Laparoscopic ablation of Uterine Fibroid Tumors
February 4, 2017

CPT has granted coders a new code for the laparoscopic ablation of uterine fibroid tumors.  As of January 1, 2017 the code is officially denoted as 58674  Laparoscopy, surgical, ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency.  The addition of this new code by CPT marks another successful transition of a code from the Category III code 0336T Laparoscopy, surgical, ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency.    Category III codes are the temporary codes set forth by CPT for emerging technology, services and procedures.  The usage of this code as a Category III code, allowed for the collection of specific data and its usage of code O336T code for ablation of fibroid tumors has allowed for CPT to create a permanent CPT code for this new technology.

The usage and transition of a Category III code to a permanent CPT code is a very good thing.  This allows for a solid RVU value allocation to the code, and insurance payers will also put this into their payment code base for standardized payment.  However, some insurance payers may still consider this to be an “experimental” code, so it is advisable to call the carrier prior to the procedure being performed to inquire about payment of this procedure with the new CPT code.

The new CPT code 58674 is primarily targeted for usage with the procedure known as Laparoscopic Radiofrequency Volumetric Thermal Ablation (RFVTA).  RFVTA is used to destroy uterine fibroids, yet preserve the uterus.  This is revolutionary for some women who still may want to pursue pregnancy, or simply to avoid major surgery such as hysterectomy, to definitively remove fibroid tumors from the uterus. 

Clinical indications and documentation

Uterine fibroids are benign, muscular tumors in a woman's uterus that can cause heavy bleeding, painful periods, pressure, and abdominal pressure, pain and distention.  According to the National Institute of Health (NIH) at least 70% of women in the US will develop fibroid tumors. Fibroids are a significant women’s health issue, and symptoms can be very mild, to very extreme.  The American Congress of Obstetricians and Gynecologists (ACOG) has stated that 39% of all hysterectomies are due to fibroid tumors and the issues related to those tumors.  Hysterectomy has been one of the more “traditional” methods for relief of fibroid uterine tumors.  The usage of a less invasive procedure that is performed laparoscopically is becoming more popular with surgeons and patients alike. 

In women who have symptoms, the most common symptoms of uterine fibroids include:
·         Heavy menstrual bleeding.
·         Menstrual periods lasting more than a week.
·         Pelvic pressure or pain.
·         Frequent urination.
·         Difficulty emptying the bladder.
·         Constipation.
·         Backache or leg pains

The ablation of these fibroid tumors via a laparoscopically delivered system of direct ablation to the uterine fibroid allows the patient to alleviate the tumor, and preserve the uterus, thereby avoiding the effects of a hysterectomy or major surgery for elimination of these tumors. 

Clinically, this procedure is considered “minimally invasive” and is performed as an outpatient procedure, and the patient can return to a normal lifestyle within 2-3 days post procedure. 

The procedure allows the surgeon to ablate targeted fibroids within the uterine cavity.  The surgeon the utilizes the laparoscopic tools to specifically targe and deliver thermal radiofrequency energy to the specific fibroid tumor with precise  tip inserted into the fibroid itself.  With this needle/tip the surgeon can then control the amount of thermal energy need to destroy the fibroid tumor. Ultrasound guidance allows the surgeon to visualize each tumor and the precise location of where the needle/tip of the tools are to be placed for successful ablation of the tumors.

RVU’s and Payment Considerations

With any new CPT code, pricing and payment is something to be considered if the physician has decided to include this into their practice.  Below is the table from CMS that outlines the National RVU’s allocated to code 58674.  This information can be accessed through the CMS link

As you can see from the above table this represents the National Payment indicators from CMS, and therefore may not represent what is the actual RVU values for your particular CMS locality.  CMS does allow for payment of this procedure, however many private insurers may still consider this an “experimental” procedure and now allow for payment of this procedure under their specific policies and contracts.

If the patient and physician have decided to pursue this method of surgical intervention, it is advisable to do a thorough pre-authorization with the patients’ insurance carrier to determine if they will pay for this new technology.  If the patient’s carries does not pay for this procedure, then you should collect up-front and/or make payment arrangements with the patient.  However, this does not preclude you, as the coder/biller from requesting a pre-authorization request for consideration of payment for this code based upon the patients’ medical necessity and the adoption of this procedure by CPT as a permanent code into the codeset, and CMS’s adoption of RVU’s.   In addition, a coder/biller can still file a claim with the patients’ insurance post procedure and submitting the operative notes and a formal request for payment.

Case Example

History:  L.W. is a 44-year-old woman (G2P2) with a 2-year history of menorrhagia and severe dysmenorrhea but no intermenstrual spotting or bleeding. We reviewed the failure of controlling her symptoms using hormonal methods, without success.

Examination: Palpation reveals that patient has an irregular, nontender uterus 8 weeks in size. Ultrasound reports for the  Transvaginal ultrasonography shows two deep, prominent, intramural fibroids. The first is 2 cm by 3 cm in size in the left lateral uterus, adjacent to the endometrial stripe. The second fibroid is 3 cm by 4 cm in the fundal region. Sonohysterography reveals no intracavitary fibroids, although the left lateral myoma has distorted the endometrial cavity.

Medical Decision Making: The patient is seeking removal of her fibroids but would like to preserve her uterus, if at all possible.  We have decided to pursue uterine-sparing fibroid treatment, performed laparoscopically instead of a hysterectomy.   Patient has signed all appropriate consents and we will contact her insurance carrier for pre-authorization and confirmation.

Operative Session/report:
Utilizing the RFVTA technique we begin with a standard 5-mm laparoscopic infraumbilical port for the camera and video laparoscope.  Placee a 12-mm port in the midline, suprapubically at the level of the uterus, and inserted the laparoscopic ultrasound probe. With the laparoscope in place I began the mapping of the uterus and outlined plan with the surgical team with the approach to destroy the fibroids.

I then inserted the handpiece containing the radiofrequency needle through the abdominal wall under laparoscopic visualization and placed the needle into the targeted fibroid using both laparoscopic and ultrasound guidance. I then accessed the first  fibroid, in the left lateral uterus and deployed the needle array to the maximum diameter necessary to begin the destruction. I then engaged the radiofrequency generator and set it for optimal destruction of the 2 x 3 cm fibroid, The fibroid was then ablated and destroyed without damage to the surrounding healthy myometrium. I then performed this same procedure upon the second fibroid in the fundal region.  This fibroid measured 3 x 4 cm with optimal destruction.  Treatment is complete, and confirmed I retracted the needle array.  I then coagulated the needle track during withdrawal of the probe, and confirmed hemostasis of all surgical areas within the uterine cavity.  All sponge and instruments counts were correct and accounted for.  The patient was then taken to recovery area in good condition.  Patient to be discharged the same day.  I will see the patient back in-office on day 3 for a postoperative check.   

Wrapping it up
As a coder, remember to code what you know, and do not assume.  If in doubt, or the documentation does not appear to be clear or is confusing, query the provider.  Good patient care requires the provider to accurately reflect the patient care via their documentation in the medical record.  Our job, as a coder, is to correlate the coding and billing to reflect the medical that was documented and provided by the physician.  If you are unsure about the coding guidelines utilize your resources such as CPT, ICD-10cm, ICD-10pcs and HCPCS. 

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CDIP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at or you can also find current coding information on her blog site:

Overview: Coding and Billing in an OB Hospitalist Practice

Coding and Billing in an OB Hospitalist Practice

In an OB Hospitalist practice, currently there are many different medical and billing scenarios each and every day that bring challenges.  Coding and billing for these scenario’s, and how they are documented, submitted to 3rd party payers, and the reimbursement back to the practice is integral to keeping an OB hospitalist practice solvent and thriving. 

At this time in the OB hospitalist specialty there are many different practice and billing models to choose from, and determining which one is right for your business can be confusing.  In addition, OB hospitalists encounter patients who don’t have access to,  or have not chosen to see a traditional OB or health care provider to oversee their care.  Many patients also rely on the OB hospitalists to respond to their emergencies and care for them around the clock.  

In many instances, we are now the go-to for traditional OB/GYN providers to augment and provide specialty hospital based services for high risk and trauma ob and GYN patients.  The OB hospitalist program concept is fairly new to the American hospital system, and coding and billing for this subspecialty poses a bigger challenge for the providers, as well as the hospital and coding/billing staff.  OB hospitalists are bearing the weight of maintaining above standard specialty patient care, in addition to being fiscally solvent.

The OB-GYN hospitalist program has a positive impact on at-risk OB patients’ health care because these programs enable the patients to have emergent care for any type of OB or GYN emergency when their own physician is unavailable on a 24/7/365 basis.  

Of course, we provide many other functions such as, supporting local obstetricians as back-up for deliveries and emergency C-sections; providing ancillary testing services for walk-in or emergent trauma situations, and also step in as an assistant surgeon for many operative procedures at a moment’s notice.  (that may or may not be OB related)

The fiscal mainstay for the OB Hospitalist practice is evaluation and management (E/M) services, which include all areas of inpatient hospital, outpatient hospital, emergency department, critical care, complex care management, and office-quick/urgent care coding.  In addition to the evaluation and management codes, procedure based CPT codes provide an enormous source of revenue, which can include surgery, interventional, diagnostic and therapeutic medicine, radiology/ultrasound services.  Not only does and OB hospitalist team provide these services, but are instrumental in also providing “down-stream” services that can impact a facility in a positive way, such as laboratory, radiology, NICU, pharmacy, nutritional services, social work services, and other areas within the facility that would not have had these financial opportunities had the OB hospitalist team not been in place.   

Each OB hospitalist program functions under many different licenses within the hospital setting.  Some practices are embedded with the Emergency Room, some are an integral part of the Labor & Delivery floor, while others operate as a “emergent outpatient” area of the hospital similar to a “quick-care, urgent-care” walk in clinic.  The most common is the OB hospitalist physician team is a “stand alone” practice comprised of OB hospitalist (specialty) physicians that function as a separately identifiable group practice that bills as a physician based practice team utilizing and coding and billing with their own practice management software and/or coding/billing team. 

Coding and billing in an OB hospitalist practice is a specialty concept within itself.  The OB hospitalists practice specialty has to provide superior care not only for the pregnant patient, but for the fetus too.  During routine coding and billing audits, many times the “hish risk” factor is overlooked or undervalued during the “scoring”  when determining the evaluation, plan of care, clinical documentation, risk factors, proposed procedures and ancillary services options when coding and billing is performed.

The nuts and bolts of traditional CPT evaluation/management and procedure codes are utilized in addition to the current ICD-10cm diagnosis codeset. Clinical documentation by the OB hospitalist is integral to success when the coder/biller has to combine all these pieces together for the evaluation and management code, the procedures performed, diagnosis, ancillary circumstances (eg pt fell, etcc) are relevant to report for reimbursement for services provided.  

The coding and billing for the OB hospitalist team should be one of your primary areas of concern as this will be the key to a successful practice.  Education in coding, billing and clinical documentation  for the entire OB hospitalist practice should be one of the important areas to review and consider, as you implement a new practice, or work to renew or revitalize a practice that is struggling with a financial issue.

Commonly coded/billed CPT Procedures
Ob Hospitalist Procedures:

·         59050/51          Fetal monitoring (IUPC)
·         59150/51          Laparoscopic treatment of ectopic pregnancy
·         59120/21          Surgical treatment of ectopic pregnancy
·         58605               Ligation or transection of fallopian tube(s),  during same hospitalization
·         58611               Tubal Ligation (Add on w/c-section)
·         59025-26           Fetal NST interpretation
·         59160               Curettage - Post Partum
·         59200              Insertion of cervical dilator
·         59300               Episiotomy or vaginal repair, by other than attending physician
·         59320               Cerclage of cervix
·         59409               Vag Deli Only
·         59412               External cephalic version, with or without tocolysis
·         59414               Placenta only delivery
·         59514-80           Assist to a surgeon for cesarean delivery
·         59514               Cesarean delivery only;
·         59525               Hysterectomy (post cesarean delivery)
·         59612               V-back delivery
·         59618               Cesarean post failed attempted vback delivery
·         59899               CPT “unlisted” services such as Bakri Balloon hemorrhage care             
·         76815               Bedside quick-peek Ultrasound
·         76818/19          Fetal Bio-physical profile(s)
·         76998               Intraoperative ultrasound

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience.  Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding.  She can be reached via e-mail at or you can also find current coding information on her blog site: