Case Studies—Female Genital System Operative Report

Abstract from Documentation:

1. Refer to the key term Hysterectomy in the Alphabetic Index. What key documentation is needed to lead to the correct coding range?

2. Time to Code:

1.Vaginal and then Laparoscopic drives the coding range. After the range of codes is identified and verified, other key documentation is needed (for example, size of uterus, removal of tubes and ovaries).

2. Index:
Hysterectomy, Vaginal, Removal Tubes/Ovaries
Code(s):
58552 Laparoscopic, surgical, with vaginal hysterectomy, for uterus 250 g or less with removal of
tube(s) and ovary(s)