OB-Gyn same day surgery, TLH, TAH, LVH, colposcopy

1. SAME DAY SURGERY:OB-
GYN
PRESENTED BY- ANIKET S. BAGATE

2. SAME DAY SURGERY:OB-GYN
1. Same day surgery is also known as ambulatory surgery, day surgery, day case
surgery and outpatient surgeries.
2. SDS does not require overnight hospital stay.
3. These surgeries performed at healthcare facility popularly known as Ambulatory
surgery centers.
4. Only few surgeries from respective system can be performed in ambulatory surgery
centers. The problems which can not be treated surgically in OP surgical centers, they
must be performed after hospitalization.

3. SAME DAY SURGERY:OB-GYN
Below are the same day surgeries of Obstetrics and gynecology with the help of Innovative
treatment methods are classified as :
• Hysteroscopic surgery- This technique does not require any incisions and has minimal
recovery time.
• Advanced laparoscopic surgery- Laparoscopic radiofrequency ablation is a less invasive
alternative to hysterectomy and myomectomy
• Robotic surgery- same as above but with more precision.
• Vaginal surgery- minimally invasive approach to major gynecologic surgery.

4. SAME DAY SURGERY:OB-GYN
• Cervical loop electrode excision procedure (LEEP)
and conization
• Diagnostic and operative hysteroscopy
• Diagnostic and operative laparoscopy
• Hysteroscopic and laparoscopic sterilization
• Laparoscopic radiofrequency ablation
• Surgical management of ectopic pregnancy
• Surgical management of missed or incomplete
abortion
• Colposcopy
• Vaginal, laparoscopic and robotic
hysterectomy
• Surgical management of congenital
anomalies
• Surgical treatment of vulvar disorders
• Sonohysterography
• CO-2 laser treatments of lower genital tract
dysplasia

5. IUD PLACEMENT(CPT: 58300, 58301)
Two types of IUDs are available for contraception, a copper-releasing
device and a hormone-releasing device.
IUD insertion procedure:
• Prior to insertion of the IUD (58300), a bimanual examination is
performed to assess the position of the uterus.
• A uterine sound is passed into the uterus and the depth of the uterine
cavity ascertained. The IUD is positioned in the insertion tube and the
insertion rod is attached. The IUD is inserted and the tube pulled back
slightly to allow expansion of the IUD.
• When the IUD is properly positioned, the insertion rod is removed
followed by removal of the insertion tube.
e.g. Mirena, Skyla, Liletta, and Kyleena

6. Procedure details
A small-diameter flexible catheter is then placed through the cervix and into the uterine cavity.
The speculum is removed and the vaginal probe is reinserted. Using separately reportable ultrasound to
visualize the uterus, sterile saline or contrast media is instilled into the uterine cavity through the tube
until the uterine cavity is adequately expanded.
For hysterosalpingography, the catheter is inserted in the same manner as for SIS. Following removal of
the speculum, separately reportable fluoroscopy is used to visualize the uterus and Fallopian tubes as
contrast media is instilled.
Coding & Billing Tips
• Radiological portion of SIS - 76831
• Radiological portion of hysterosalpingography - 74740
SALINE INFUSION SONOHYSTEROGRAPHY (SIS)-
58340

7. • 58100 Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any
method (separate procedure)
• 58110 Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code
for primary procedure)
Procedure detail:
A speculum is placed in the vagina. The cervix is exposed and cleansed with antiseptic solution. The anterior cervical
lip is grasped with a tenaculum and the uterus is sounded. An endometrial curette is passed through the cervix and
biopsies are taken from multiple sites in the uterus. Biopsies may also be taken of the endocervical canal. The curette
is withdrawn and the tissue sent to pathology. The tenaculum is removed and bleeding from the cervix controlled with
pressure.
Use code 58100 if endometrial biopsy is performed alone as a separate procedure. Use code 58110 if it is performed
as an add-on service in conjunction with a separately reportable colposcopy procedure
(Use 58110 in conjunction with 57420, 57421, 57452-57461)
ENDOMETRIAL BIOPSY

8. DIAGNOSTIC AND OPERATIVE HYSTEROSCOPY
(CPT- 58555-58565)
• Diagnostic hysterectomy- is a procedure that allows your doctor to look inside your uterus in order to diagnose conditions
such as fibroids and polyps (non-cancerous growths in the womb) and used to investigate symptoms or problems – such
as heavy periods, unusual vaginal bleeding, postmenopausal bleeding, pelvic pain, repeated miscarriages or difficulty
getting pregnant.
• Hysteroscopy is done using hysteroscope.
How diagnostic hysteroscopy procedure done/performed?( Separate Procedure)
1. A bimanual pelvic exam is performed prior to hysteroscope insertion.
2. A single-tooth tenaculum is placed on the anterior cervical lip.
3. The cervix is then numbed and dilated using metal dilators to allow insertion of the
hysteroscope, which is placed into the endocervical canal and advanced into the uterine
cavity.
4. Under direct vision while simultaneously expanding the uterus with saline or carbon dioxide.
5. The uterus is then examined for polyps, fibroids, or other abnormalities.

9. Apart from diagnostic hysteroscopy, if surgeon operates in the endometrium, it becomes surgical and based on that
CPT selection will differ.
Coding Tip: Code 58555 is included in 58558-58565, Surgical hysteroscopy always includes diagnostic hysteroscopy.
58555 Hysteroscopy, diagnostic (separate procedure)
58558 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C
58559 Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method)
58560 Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)
58561 Hysteroscopy, surgical; with removal of leiomyomata
58562 Hysteroscopy, surgical; with removal of impacted foreign body
58563 Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation)
58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent
implants.
DIAGNOSTIC AND OPERATIVE HYSTEROSCOPY
(CPT- 58555-58565)

10. Medical terms understanding:
Biopsy: an examination of tissue removed from a living body to discover the presence, cause, or
extent of a disease
Intrauterine adhesions-scar tissue builds up between the inner walls of the uterus
Leiomyomata- (fibroids)is a benign smooth muscle tumor that very rarely becomes cancer
Lysis- the disintegration of a cell by rupture of the cell wall
Resection- the process of cutting out tissue or part of an organ
Endometrial ablation- destroy the endometrial lining of the uterus
Fallopian tube cannulation- procedure used to help clear blockages in a woman’s fallopian tubes
DIAGNOSTIC AND OPERATIVE HYSTEROSCOPY
(CPT- 58555-58565)

11. How Diagnostic laparoscopy done/performed?
1. A periumbilical port is placed and pneumoperitoneum established by
the insufflation of air.
2. The laparoscope is inserted and the entire abdominal cavity,
peritoneum, and/or omentum inspected for signs of malignancy,
disease, or injury using a video camera.
3. A biopsy brush may be inserted through the laparoscope and cell
samples obtained. Alternatively, cells may be obtained by washing,
which involves instilling a small amount of sterile saline through the
laparoscope and then aspirating the fluid.
4. Brushings or washings are sent to the laboratory for separately
reportable cytological evaluation.
DIAGNOSTIC LAPAROSCOPY
(CPT 49320-49321)

12. Apart from diagnostic laparoscopy, if surgeon operates in the uterus, it becomes surgical laparoscopy and based on
that CPT selection will differ.
Coding Tip: Surgical laparoscopy always includes diagnostic laparoscopy.
Procedure understanding: A total laparoscopic hysterectomy (TLH) is performed to remove a uterus.
1. A urinary catheter is inserted into the bladder through the urethra, the cervix is dilated, and a uterine sound is
inserted to measure the uterine length. A uterine manipulator is placed transvaginally through the cervix.
2. An incision is made below the umbilicus, the laparoscope is inserted, and the abdomen is insufflated. An
additional suprapubic incision and bilateral incisions near the hip bones are made for other surgical instruments.
3. An incision is made into the anterior aspect of the vagina and extended laterally and posteriorly, while preserving
the uterosacral ligament.
4. The uterus and cervix are then delivered into the vagina and removed.
OPERATIVE LAPAROSCOPY
(CPT 58570- 58575- TOTAL LAPAROSCOPIC
HYSTERECTOMY)

13. 58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less
58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or
ovary(s)
58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g
58573 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s)
and/or ovary(s)
58575 Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with
omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed
OPERATIVE LAPAROSCOPY
(CPT 58570- 58575- TOTAL LAPAROSCOPIC
HYSTERECTOMY)

14. The LAVH(laparoscopically assisted vaginal hysterectomy) is
same as TLH, but with little difference.
How to identify difference between TLH vs LAVH
• Code selection for a TLH versus a LAVH depends on how
the uterine cervix and body are detached from the
supporting structures.
• In a TLH procedure, all structures are detached via the
laparoscopic tools/incisions – the removal of the structures
can be performed either via the laparoscopic incision or
the vagina.
• A LAVH procedure does use a laparoscope, but it is used
only for the initial part of the procedure as a guidance and
visualization tool. An incision into the vagina is used to
detach the structures. The removal of the structures must
be done vaginally. (Both uterus and cervix)
OPERATIVE LAPAROSCOPY
(CPT 58550- 58554 LAVH)
Coding Tip: The fact that the uterus is removed
through the vagina does not indicate that the
procedure performed was a laparoscopically
assisted vaginal hysterectomy.

15. CPT: LAVH
• 58550 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less
• 58552 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less;
with removal of tube(s) and/or ovary(s)
• 58553 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than
250 g
• 58554 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than
250 g; with removal of tube(s) and/or ovary(s)
OPERATIVE LAPAROSCOPY
(CPT 58550- 58554 LAVH)

16. • Laparoscopic supracervical hysterectomy, LSH is a minimally invasive way to remove the uterus
as an alternative to total abdominal hysterectomy.
• LSH maintains better pelvic support because the ligaments that hold up the vagina and cervix
are left intact. This procedure also preserves sexual function by maintaining the cervix and its
secretory glands.
• A laparoscopic supracervical hysterectomy removes only the body of the uterus and leaves the
cervix in place.
• For a LSH, the uterus is removed through a laparoscopic incision with the use of a special
device (called a morcellator) that removes the uterus in small strips in order to avoid a larger
abdominal incision
A power morcellator is a surgical tool that doctors use to cut bigger chunks of tissue into
smaller ones, usually during laparoscopic surgery
OPERATIVE LAPAROSCOPY
(CPT58541-58544- LSH)

17. CPT: LSH
• 58541 Laparoscopy, surgical, supracervical hysterectomy, for
uterus 250 g or less
• 58542 Laparoscopy, surgical, supracervical hysterectomy, for
uterus 250 g or less; with removal of tube(s) and/or ovary(s)
• 58543 Laparoscopy, surgical, supracervical hysterectomy, for
uterus greater than 250 g
• 58544 Laparoscopy, surgical, supracervical hysterectomy, for
uterus greater than 250 g; with removal of tube(s) and/or
ovary(s)
OPERATIVE LAPAROSCOPY
(CPT58541-58544- LSH)

18. • ObGyns increasingly use robotic-assisted laparoscopy to
perform several procedures, including hysterectomies,
sacrocolpopexies and myomectomies.
• Intuitive Surgical, Inc., manufacturer of the da Vinci robotic
laparoscopic surgical system, concurs, instructing
physicians that "robotic-assistance is, in fact, covered by
routine and customary laparoscopic CPT
• According to the AMA, robotic-assistance does not require
unique codes or modifiers, and current laparoscopic Level I
CPT codes may be used.
• You should not report unlisted procedure codes or modifier
22 Increased procedural services for robotic assistance
(except perhaps, for instance, there is no existing
laparoscopic code to describe a procedure).
ROBOTIC-ASSISTED LAPAROSCOPY
Coding Tip:
• If your payer accepts HCPCS Level II S codes, you
may report S2900 Surgical techniques requiring use
of robotic surgical system (List separately in addition
to code for primary procedure) in addition to the
primary procedure code to identify the procedure as
robotic-assisted.
• Note that S codes are not payable under Medicare,
and likely won’t result in additional payment from any
insurer.
• Time the ObGyn spent learning to use the robotic
equipment should not be counted toward your
modifier 22 claim.

19. ROBOTIC-ASSISTED LAPAROSCOPY
• 58546 (...; myomectomy, excision, 5 or more
intramural myomas and/or intramural myomas with
total weight greater than 250 grams
• 58548 (...; with radical hysterectomy, with bilateral
total pelvic lymphadenectomy and para-aortic
lymph node sampling [biopsy], with removal of
tube[s] and ovary[s], if performed)
• 58570 (...; with total hysterectomy, for uterus 250 g
or less)
• 58571 (...; with total hysterectomy, for uterus 250 g
or less, with removal of tube[s] and/or ovary[s])
• 58572 (...; with total hysterectomy, for uterus
greater than 250 g)
• 58573 (...; with total hysterectomy, for uterus
greater than 250 g, with removal of tube[s] and/or
ovary[s])
Codes that may apply include, but are not limited to:
• 57425 (laparoscopy, surgical: colpopexy
[suspension of vaginal apex])
• 58541 (...; supracervical hysterectomy, for uterus
250 g or less)
• 58542 (...; supracervical hysterectomy, for uterus
250 g or less, with removal of tube[s] and/or
ovary[s])
• 58543 (...; supracervical hysterectomy, for uterus
greater than 250 g)
• 58544 (...; supracervical hysterectomy, for uterus
greater than 250 g, with removal of tube[s] and/or
ovary[s] )
• 58545 (...; myomectomy, excision, 1 to 4
intramural myomas with total weight of 250 grams
or less and/or removal of surface myomas)

20. • 58660 Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure)
The laparoscope is inserted and the abdominal cavity is inspected. Scar tissue around the
tubes and ovaries is meticulously divided. Adhesiolysis may be performed by blunt or sharp
dissection, laser, or electrocautery. The procedure continues until all adhesions have been severed
and the mobility and function of the tubes and ovaries are restored.
• 58661 Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy
and/or salpingectomy)
The physician may remove part or all of one or both fallopian tubes and/or ovaries.
OPERATIVE LAPAROSCOPY
(CPT: 58660-58662, CPT 58670-58673)

21. • 58662 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or
peritoneal surface by any method
Lesions in the ovary, pelvic viscera, or peritoneal surface are excised using a clip or
scissors, or destroyed using a laser or electrocautery.
• 58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
In 58670, a cautery device is introduced and a section of the fallopian tube is destroyed. The
physician may transect the fallopian tubes.
OPERATIVE LAPAROSCOPY
(CPT: 58660-58662, CPT 58670-58673)

22. • 58671 Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring)
In 58671, the tongs of the band instrument are loaded with the occlusion device (band, clip,
or Falope ring)
OPERATIVE LAPAROSCOPY
(CPT: 58660-58662, CPT 58670-58673)

23. 1. 59150 Laparoscopic treatment of ectopic pregnancy; without
salpingectomy and/or oophorectomy
2. 59151 Laparoscopic treatment of ectopic pregnancy; with
salpingectomy and/or oophorectomy
• CPT 59150: The site of gestation is located with a laparoscope, and a
small incision is made above the site. The ectopic pregnancy is then
removed.
• CPT 59151: In 59151, the ectopic pregnancy is treated by excising the
tube and/or ovary
LAPAROSCOPIC TREATMENT OF ECTOPIC
PREGNANCY
(CPT: 59150, 59151)

24. Colposcopy is a medical diagnostic procedure to visually examine the cervix as well as the vagina and
vulva using a colposcope.
• 57420 Colposcopy of the entire vagina, with cervix if present
• 57452 Colposcopy of the cervix including upper/adjacent vagina
• 57454 Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and
endocervical curettage
• 57455 Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix
• 57456 Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage
• 57460 Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the
cervix
• 57461 Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of
the cervix
COLPOSCOPY
(CPT 57420, 57452-57461)

25. Medical terms understanding:
• Biopsy Cervix: a sample of tissue is taken from the cervix, the
cylinder-shaped structure that connects the vagina and the
uterus.
• Endocervical curettage- procedure in which the mucous
membrane of the cervical canal is scraped using a spoon-
shaped instrument called a curette.
• Main part of colposcopy: Acetic acid application to allow better
visualization of abnormal cells. Following the application of
acetic acid, different-colored filters are used to visualize blood
vessels and any abnormal blood vessel patterns noted. Next,
the cervix and upper adjacent vagina are painted with an iodine
solution that stains the glycogen in the cells. Normal cells stain a
dark-brown color. Any areas that do not stain are biopsied
COLPOSCOPY
(CPT 57420, 57452-57461

26. • loop electrode biopsy- The doctor then inserts an electrically charged loop of wire into the cervix.
This loop is passed through all abnormal areas in the cervix to cut out a thin layer, thereby
removing the abnormal tissue.
• loop electrode conization - Conization is also called a cone biopsy because it removes a cone-
shaped section of abnormal tissue for laboratory examination.
COLPOSCOPY
(CPT 57420, 57452-57461

27. • 56820 Colposcopy of the vulva
• 56821 Colposcopy of the vulva; with biopsy(s)
Procedure detail:
1. A colposcope is an instrument that looks like a pair of binoculars mounted on a pedestal with a
light attached. The colposcope lenses magnify the tissue of the vulva, allowing better
visualization of abnormal tissue.
2. Acetic acid is applied to allow better visualization of abnormal cells. Following the application of
acetic acid, different-colored filters are used to visualize blood vessels and any abnormal blood
vessel patterns noted. Next, the vulva is painted with an iodine solution that stains the glycogen
in the cells. Normal cells stain a dark-brown color. Any areas that do not stain are biopsied.
COLPOSCOPY OF VULVA
(CPT:56820-56821)

28. • 57520 Conization of cervix, with or without fulguration, with or without dilation and curettage, with
or without repair; cold knife or laser.
A cone or wedge-shaped section of cervical tissue is removed using blade excision (cold
knife) including the entire transformation zone and a 2-3 mm margin of healthy tissue
• 57522 Conization of cervix, with or without fulguration, with or without dilation and curettage, with
or without repair; loop electrode excision
LEEP stands for loop electrosurgical excision procedure.
Fulguration, dilation and curettage, and cervical repair are performed if needed as described above.
CONIZATION OF CERVIX ( CPT: 57520-57522)

29. THANK YOU !!!
Questions?