Medical Coding Guidelines: January 2022

Tuesday, January 18, 2022

Nasopharyngoscopy With Dilation of Eustachian Tube

CPT Assistant, April 2021, Volume 31, Issue 4, page 12

For the Current Procedural Terminology (CPT®) code set, two new Category I codes (69705, 69706) were added to the Middle Ear subsection of the Auditory System section. This article provides an overview of these new codes.

Middle Ear

Other Procedures

69705

Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); unilateral

69706

bilateral

(Do not report 69705, 69706 in conjunction with 31231, 92511)

Prior to 2021, there was no specific CPT code to report surgical nasopharyngoscopy with dilation of the eustachian tube (ie, balloon dilation). This procedure was previously reported with code 69799, Unlisted procedure, middle ear.

The new procedure is clinically referred to as eustachian tube balloon dilation (ETBD), which may be performed for the treatment of disorders related to middle ear aeration or ventilation (eg, obstructive eustachian tube dysfunction [OETD]) contributing to middle ear effusion and related disorders (eg, retraction pockets, cholesteatoma, atelectatic otitis media).

Although inflation of the eustachian tube is included in codes 69420, Myringotomy including aspiration and/or eustachian tube inflation, and 69421, Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia, these inflation procedures are performed through an incision in the eardrum and do not describe nasopharyngoscopic ETBD. An exclusionary parenthetical note was added after code 69706 to indicate that codes 69705 and 69706 should not be reported with code 31231, Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure), or 92511, Nasopharyngoscopy with endoscope (separate procedure).

The following clinical examples and procedural descriptions reflect typical clinical situations for which codes 69705 and 69706 would be appropriately reported.

Clinical Example (69705)

A 45-year-old female with adult life-long history of difficulty equalizing her left ear with altitude changes develops a left middle ear effusion after a flight. Despite medical management over 3 months, her left middle ear effusion persists with a type B tympanogram and conductive hearing loss. She is scheduled for surgical nasopharyngoscopy with left eustachian tube dilation.

Description of Procedure (69705)

Remove previously placed pledgets. Under endoscopic visualization, place pledgets soaked in decongestant and anesthetic in the nasopharynx followed by a wait-time for them to take effect. Remove pledgets and inject an intranasal anesthetic/vasoconstrictive agent into the middle turbinate followed by a wait-time for this to take effect. Holding the guide catheter by the proximal hub and under endoscopic visualization, insert it through the nose on the side to be treated and near the orifice of the eustachian tube. Then rotate and stabilize the guide catheter so that the tip angle is aligned with the trajectory of the eustachian tube. Advance the balloon catheter through the guide into the eustachian tube. Inflate the balloon to the desired pressure while monitoring the diameter, shape, and position of the balloon under endoscopic visualization and monitoring for any signs of bleeding from the internal carotid artery. Perform additional inflation followed by balloon deflation, retract into the guide catheter, and remove along with the entire system.

Clinical Example (69706)

A 56-year-old male with adult life-long history of difficulty equalizing his ears with flights develops an upper respiratory infection and subsequent middle ear effusion bilaterally. Despite medical management over three months, his middle ear effusions persist with type B tympanograms and conductive hearing loss. He is scheduled for surgical nasopharyngoscopy with bilateral eustachian tube dilation.

Description of Procedure (69706)

Surgery: Musculoskeletal System, Peroneus Brevis Tendon Transfer, 27690 (Q&A)

CPT Assistant, May 2021, Volume 31, Issue 5, page 13

Question:

Should code 27690 or 27691 be reported if a physician performed a transfer of the peroneus brevis tendon to the peroneus longus tendon?

Answer:

Peroneal tendon transfers to the same side of the foot should be reported as a superficial tendon transfer; therefore, report code 27690, Transfer or transplant of single tendon (with muscle redirection or rerouting); superficial (eg, anterior tibial extensors into midfoot).

Surgery: Musculoskeletal System, Proximal Interphalangeal (PIP) Joint Release, 26123 (Q&A)

CPT Assistant, May 2021, Volume 31, Issue 5, page 13

Question:

What specifically constitutes a release of the proximal interphalangeal (PIP) joint as described in code 26123? Is excision of the cord sufficient to report a release or does it require capsulotomy, capsulectomy, and/or volar plate release?

Answer:

Excision of the cord to release the PIP joint is sufficient to report code 26123, Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft). Skin lengthening through Z-plasty or skin graft, excision of the diseased fascial cord, and any necessary capsuloligamentous releases, when performed, are inherent to code 26123 and may not be reported separately.

Surgery: Integumentary System, Mastotomy with Biopsy, 19020, 19101 (Q&A)

CPT Assistant, May 2021, Volume 31, Issue 5, page 13

Question:

While performing a mastotomy on a patient for a breast abscess, the surgeon noticed abnormal tissue and performed a biopsy of the tissue for pathology review. May both procedures be reported?

Answer:

Yes, a biopsy of a mass or lesion is not inherent to a mastotomy for a breast abscess. Both codes 19020, Mastotomy with exploration or drainage of abscess, deep, and 19101, Biopsy of breast; open, incisional, may be reported.

Coding Brief: Breast Localization Clips Placement and Mastectomy Procedures

CPT Assistant, May 2021, Volume 31, Issue 5, page 11

For the Current Procedural Terminology (CPT®) 2018 code set, a new parenthetical note was added to the Breast subsection of the Integumentary System section that states: "[i]ntraoperative placement of clip[s] is not separately reported." Since publication of these changes, there have been questions about when to correctly report percutaneous placement of breast localization device(s) (19281-19288), such as a clip, when performed the same day but prior to a mastectomy procedure (19301-19307). This coding brief will clarify appropriate reporting of these separate services when performed on the same day.

Coding Tip

"Intraoperative" refers to the "skin-to-skin" work of an operative procedure. It does not include pre- or post-service work, which may include separately reportable procedures or services.

For the CPT 2020 code set, new guidelines were added in the introduction of the Breast subsection to instruct reporting the appropriate percutaneous image-guided localization device placement code(s) (19281-19288) when performed prior to an open breast biopsy or open excision of a breast lesion. This includes percutaneous placement of a breast localization device prior to the intraoperative (ie, skin-to-skin) component of an open mastectomy procedure.

During image-guided percutaneous clip placement, typically performed by a radiologist or surgeon, views are obtained which will be used for pre-surgical planning. For example, part of the preservice work for a partial mastectomy (19302) is to review the localization mammogram with the radiologist, who performed the needle-localization procedure, so that the surgeon can plan the optimal location of the skin incisions and operative approach to the area of concern.

A typical scenario is one that would involve a patient who undergoes image-guided percutaneous placement of a localization device (eg, clip or wire) in the radiology department, and later undergoes an open partial mastectomy in the operating room. If, for example, mammographic imaging were used to percutaneously place the device, the radiologist would report code 19281, Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance. The radiologist does not append a modifier to code 19281 if no other services were performed.

A less common scenario involves the surgeon performing the image-guided percutaneous placement of a localization device prior to starting an open mastectomy procedure, either in another suite, in the preoperative holding area, or in the operating room. If, for example, ultrasound imaging were used to percutaneously place the device, the surgeon would report code 19285, Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance, with modifier 59, Distinct Procedural Service, appended to indicate that the procedure was distinct from the mastectomy procedure. Note that Healthcare Common Procedure Coding System (HCPCS) modifier XE, Separate Encounter, may also be appropriately reported depending on the policy of third-party payers.

In summary, the intent of the parenthetical note of "(Intraoperative placement of clip[s] is not separately reported)" following the mastectomy codes was to disallow and prevent separate reporting of placing a device in the open mastectomy wound or cavity, for example, to mark the margins of the excision for future operations or services (eg, radiation therapy). This was to acknowledge the minimal work required to place a clip or wire in an open wound. The qualifying factor for reporting image-guided percutaneous localization device placement is that the device is not placed intraoperatively (ie, during the skin-to-skin portion of a mastectomy procedure), which would not be separately reportable.

Surgery: Digestive System, 42820, 42821, 42825, 42826 (Q&A)

CPT Assistant, June 2021, Volume 31, Issue 6, page 14

Question:

What is the correct coding for an intracapsular tonsillectomy with adenoidectomy? Is it appropriate to indicate reduced services by appending a modifier to the code because a thin layer of tonsil was left in place?

Answer:

It would be appropriate to report the age-appropriate tonsillectomy with adenoidectomy code 42820, Tonsillectomy and adenoidectomy; younger than age 12, or 42821, Tonsillectomy and adenoidectomy; age 12 or over, without appending modifier 52, Reduced Services. Similarly, if only an intracapsular tonsillectomy was performed, it would be reported with the unmodified and age-appropriate code 42825, Tonsillectomy, primary or secondary; younger than age 12, or 42826, Tonsillectomy, primary or secondary; age 12 or over. This is because the work involved and the surgical outcome achieved are essentially the same as a classic tonsillectomy. To clarify, "intracapsular" refers only to the tonsillectomy; there is no capsule associated with the adenoids. There is no coding difference for tonsillectomies performed with different modalities (eg, scalpel, electrocautery, laser, radiofrequency ablation) because the work and outcomes are similar.

Surgery: Urinary System, 52601 (Q&A)

CPT Assistant, July 2021, Volume 31, Issue 7, page 9

Question:

When reporting code 52601, do all procedures referenced in parentheses need to be performed? Or just some of them?

Answer:

The procedures listed in parentheses for code 52601, Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included), are procedures that would not be coded separately, if performed. These procedures are not required to be performed in order to report code 52601; however, they are not separately reportable, if performed. This code describes prostate resection via transurethral approach using an electrosurgical device and is intended to describe an initial resection of the prostate.

Surgery: Integumentary System, 15734 (Q&A)

CPT Assistant, July 2021, Volume 31, Issue 7, page 8

Question:

A physician performs bilateral partial capsulotomies, removes the tissue expanders, performs partial capsulectomies, and performs thermal capsulorrhaphies. The physician also performs bilateral pectoralis muscle repair to anchor the muscle back to the chest wall, places permanent implants, and injects harvested fat into each breast (60 mL LT, 70 mL RT). Is it appropriate to report two units of code 15734 for the pectoralis muscle repair?

Answer:

No, it would not be appropriate to report an additional unit of code 15734, Muscle, myocutaneous, or fasciocutaneous flap; trunk, to anchor the pectoralis muscle to the chest wall. Manipulation of the pectoralis major, when performed, is considered part of reconstructive breast surgery, and it does not constitute as a muscle flap as required by code 15734.

Coding Clarification: Reporting Code 31237 for Endoscopic Sinus Debridement

CPT Assistant, July 2021, Volume 31, Issue 7, page 3

Endoscopic debridements following routine endoscopic sinus surgery (ESS) may be performed to improve long-term outcomes, as debridement of necrotic material can facilitate healing. While limited use of debridements will suffice in most cases, there are clinical scenarios in which no debridement may be needed. There are also scenarios in which a patient may require more frequent or long-term debridements. This may include, but is not limited to, those patients with persistent and infected crusting with necrotic tissue or biofilms at the surgical site, adhesion formation compromising healing and/or visualization, underlying immunologic or mucociliary disorders associated with delayed healing, and retained foreign material that may be interfering with wound healing. The frequency and length of time for which debridement is medically necessary will vary from case to case and must be individualized and documented. This article will clarify the appropriate reporting of code 31237 when debridement is performed.

Endoscopy

31237

Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure)

Code 31237 is used to report postoperative debridement, as well as polypectomy and/or biopsy, which may be required for treatment of nasal polyps unresponsive to medical management or for suspected neoplasm.

The generally accepted definition of surgical debridement involves the removal of necrotic or infected soft tissue and bone (including biofilms) or retained foreign material to facilitate wound healing. There are references to various descriptions of debridement in the Current Procedural Terminology (CPT®) code set. For example, the descriptor of code 97597, Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less, in the Active Wound Care Management subsection of the Medicine section notes various methods of debridement, including sharp selective debridement with scissors, scalpel, and forceps.

Although there is no definition for intranasal sinus debridement in the CPT code set, the clinical concepts are parallel to debridement as used in other sections of the CPT code set and in surgical practice generally. Code 31237 includes endoscopic use of cutting and grasping instruments for the removal of necrotic, diseased tissue that is interfering with wound healing in a postoperative patient. Code 31237 may not be reported for endoscopically examining the operative site and suctioning blood, clots, and/or inspissated mucus alone. Assuming all other code criteria are satisfied, simple suctioning of such material would be inherent to code 31231, Nasal endoscopy, diagnostic, unilateral or bilateral.

ESS procedures are predominantly assigned 0-day global periods, but several procedures have assigned 10-day global periods. Endoscopic debridements of the operative sites performed beyond the code-specific global period are reported with code 31237 and, if bilateral, with modifier 50, Bilateral Procedure, appended. Sinus debridements within the global period of another intranasal procedure that generally does not require debridement, such as septoplasty, may be reported by appending modifier 79, Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period, to code 31237.

Documentation associated with the use of code 31237 should include the medical necessity for performing debridement, specific site(s) addressed, type of anesthesia, depth of material debrided with instruments and endoscopes utilized, manner of hemostasis, and use of and/or the type of packing. As with all procedures, complications and any other relevant factors should be included.

The article "Coding Consultation" in the December 2001 issue of CPT® Assistant, as well as the article "Coding Clarification: Post-Endoscopic Sinus Surgery Debridements" in the December 2011 issue have also addressed this topic.

Surgery: Nervous System, Endoscopic Rhizotomy

Question:

When the physician performs a medial branch endoscopic rhizotomy at L3, L4, and L5 on the right side, would three units of code 64772 be reported? In addition, if the procedures were performed bilaterally, how should they be reported?

Answer:

There is no specific CPT code to describe an endoscopic rhizotomy procedure. Therefore, code 64999, Unlisted procedure, nervous system, should be reported for the entire procedure as a single unit and without appending a modifier. When reporting an unlisted code to describe a procedure or service, it is necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure; and the time, effort, and equipment necessary to provide the service.

Surgery: Digestive System, Colonoscopy, 45380 (Q&A)

CPT Assistant, August 2021, Volume 31, Issue 8, page 15

Question:

A physician performed a colonoscopy and reached the cecum. The physician took several biopsies but plans to repeat the procedure at a later time due to poor patient preparation. How should this procedure be reported? Should modifier 52 or 53 be appended?

Answer:

This procedure would be reported with code 45380, Colonoscopy, flexible; with biopsy, single or multiple. A modifier should not be appended because the complete procedure was performed. The Colonoscopy Decision Tree in the CPT 2021 code set instructs that modifier 53, Discontinued Procedure, should be appended to code 45378, Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure), if the physician were unable to advance the colonoscope to the cecum, and modifier 52, Reduced Services, is appended to therapeutic colonoscopy codes 45379-45398 if the physician was unable to advance the colonoscope to the cecum. In the scenario presented, the cecum was reached; therefore, modifier 52 and modifier 53 would not apply.

Surgery: Musculoskeletal System, Debridement of Synovial Tissue

CPT Assistant, August 2021, Volume 31, Issue 8, page 14

Question:

When a physician performs a knee arthroscopy and documents debridement of synovitis, would it be appropriate to report the procedure as synovectomy or debridement?

Answer:

Surgical debridement of synovial tissue is a synovectomy. If arthroscopic synovectomy is performed in one compartment of the knee, report code 29875, Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure). If arthroscopic synovectomy is performed in two or more compartments of the knee, report code 29876, Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral).

Surgery: Musculoskeletal System, Interpositional Arthroplasty, 25445, 25447 (Q&A)

CPT Assistant, August 2021, Volume 31, Issue 8, page 14

Question:

A physician placed a rolled-up piece of allograft tissue in the defect in which the trapezium was excised during an interpositional arthroplasty procedure. An abductor pollicis longus to flexor carpi radialis (APL-to-FCR) suspensionplasty was also performed during the operative session. Would the scenario presented be reported with code 25447 as an interpositional arthroplasty? Or is the rolled-up piece of allograft tissue considered a prosthetic replacement of the trapezium and reported with code 25445?

Answer:

When the trapezium is excised and autologous tissue is utilized between the scaphoid and thumb metacarpal to perform a tendon suspensionplasty, as described in the scenario presented, code 25447, Arthroplasty, interposition, intercarpal or carpometacarpal joints, may be reported. In circumstances in which allograft tissue is the sole interpositional support material without use of autologous tissue (eg, APL-to-FCR suspensionplasty), code 25445, Arthroplasty with prosthetic replacement, trapezium, would be reported.

Surgery: Musculoskeletal System, Excision of Mucous Cyst, 26160, 26235, 26236 (Q&A)

CPT Assistant, August 2021, Volume 31, Issue 8, page 14

Question:

What is the correct CPT code(s) to report for excision of a mucous cyst from a finger joint with excisional debridement of underlying osteophyte(s)?

Answer:

In the scenario presented, two codes may be reported. The work of soft tissue cyst excision may be reported with code 26160, Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or finger. The excisional debridement of the dominant bone pathology (eg, osteophyte) is reported based on the bone that requires excisional debridement. Report either code 26235, Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); proximal or middle phalanx of finger, or 26236, Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); distal phalanx of finger. The term "osteomyelitis" in codes 26235 and 26236 is only an example of why partial bone excision may be performed, but the presence of osteomyelitis is not required in order to report these codes. In addition, osteophytes are not bone tumors or bone cysts; therefore, code 26210, Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger, would not apply.

Surgery: Integumentary System, 10160, 76942 (Q&A)

CPT Assistant, August 2021, Volume 31, Issue 8, page 14

Question:

What Current Procedural Terminology (CPT®) code should be reported for aspiration of postoperative breast seroma with ultrasound guidance, when performed outside the assigned global period of the previous breast procedure? Under direct sonographic guidance, an 18-gauge spinal needle was inserted into the breast. Subsequent aspiration of approximately 25 mL of serosanguineous fluid was performed and complete collapse of the seroma was achieved.

Answer:

In the scenario presented, it would be appropriate to report codes 10160, Puncture aspiration of abscess, hematoma, bulla, or cyst, for the seroma aspiration and 76942, Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation, for the imaging guidance. However, if the seroma is aspirated in the office during the assigned global period of the breast procedure, it would not be separately reportable.

Pathology and Laboratory Tier 2 to Tier 1 Code Conversions

CPT Assistant, August 2021, Volume 31, Issue 8, page 10

Important changes were made to the Molecular Pathology subsection of the Pathology and Laboratory section of the Current Procedural Terminology (CPT?®) 2021 code set. In particular, four new Tier 1 codes were established to describe genetic analysis for follicular lymphoma (81278) and myeloproliferative neoplasms or disorders (81279, 81338, 81339). Previously, these services were reported with Tier 2 codes 81402 and/or 81403. However, since the initial inclusion of these codes in the Tier 2 subsection, their usage has increased and warrants conversion to separately identifiable Tier 1 codes. This article provides an overview of the appropriate use of these new codes.

Tier 1 Molecular Pathology Procedures

81278

IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma) translocation analysis, major breakpoint region (MBR) and minor cluster region (mcr) breakpoints, qualitative or quantitative

81279

JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) targeted sequence analysis (eg, exons 12 and 13)

81338

MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; common variants (eg, W515A, W515K, W515L, W515R)

81339

sequence analysis, exon 10

Translocation is chromosomal rearrangement in which a region of one chromosome attaches to a region of another chromosome following double-stranded breaks in the respective chromosomes. Medically relevant translocations in major breakpoint regions (MBRs) in cancer generate fusion proteins that juxtapose the active sites of oncogenes to promoter-containing regions of other genes, resulting in increased oncogenic activity that drives the malignant process. This process is illustrated by the IGH@/BCL2 translocation, which places the active region of the BCL2 oncogene next to the regulatory regions of the immunoglobulin heavy chain gene and is characteristic of follicular lymphoma. Detection of the IGH@/BCL2 translocation in a patient can help identify potential treatment options.

Code 81278 was established to report analysis of the IGH@BCL2 translocation. This test was previously reported with Tier 2 code 81402, Molecular pathology procedure, Level 3 (eg, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants [typically using non-sequencing target variant analysis], immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants of 1 exon, loss of heterozygosity [LOH], uniparental disomy [UPD]).

Code 81279 was established to report targeted sequence analysis of exons 12 and 13 of the JAK2 gene. Mutations in JAK2 are important pathogenetic drivers of myeloproliferative neoplasms, which are defined by abnormal production of red or white blood cells, platelets, or the development of marrow fibrosis. Previously, this test was reported with Tier 2 code 81403, Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons).

Codes 81338 and 81339 were established for reporting sequence analysis and identifying common variants of MPL, another gene associated with myeloproliferative neoplasms. Code 81338 is used to report analysis for common variants of the MPL gene (eg, W515A, W515K, W515L, W515R), whereas code 81339 is reported for sequence analysis of MPL exon 10. These two tests were previously reported with Tier 2 codes 81402 and 81403, respectively.

The following clinical examples and procedural descriptions reflect typical clinical scenarios for which these new codes would be appropriately reported.

Clinical Example (81278)

A 62-year-old male undergoes a biopsy of an enlarged lymph node and is given a histologic diagnosis of follicular lymphoma. A portion of the biopsied specimen is submitted for IGH@/BCL2(t(14;18)) translocation analysis.

Description of Procedure (81278)

Extract and evaluate high-quality DNA from biopsied material for the IGH@/BCL2(t(14;18)) translocation by real-time PCR amplification. A pathologist or other qualified health care professional analyzes the data and prepares and signs a report. Communicate the results of the patient's translocation status to appropriate health care professionals.

Clinical Example (81279)

A 60-year-old male presents to his physician with pruritis and headaches and was found to have an increased hemoglobin concentration of 18.0 g/dL. There is clinical suspicion for polycythemia vera. Following referral to hematology, a bone marrow biopsy showed panhyperplasia with atypical megakaryocytes. JAK2 V617F point mutation testing was negative. A blood sample was submitted for targeted sequencing evaluation of JAK2 exons 12 and 13.

Description of Procedure (81279)

Isolate and subject high-quality genomic DNA from peripheral blood to targeted sequencing of JAK2 exons 12 and 13. A pathologist or other qualified health care professional analyzes the data and composes a report specifying the patient's mutation status. Communicate the results to the appropriate health care professionals.

Clinical Example (81338)

A 65-year-old female presents to a physician for a routine visit and is found to have a markedly elevated platelet count. Repeat testing on a follow-up visit showed similar results. The patient was referred to a hematologist/oncologist, who ordered fluorescence in situ hybridization (FISH) testing for BCR-ABL1, molecular testing for JAK2 mutations, and a bone marrow biopsy. BCR-ABL1 and JAK2 testing was negative, and the bone marrow biopsy showed increased numbers of enlarged megakaryocytes. To diagnose the patient with a myeloproliferative disorder, the physician requested MPL W515 testing and CALR testing.

Description of Procedure (81338)

Isolate and prepare high-quality genomic DNA from whole blood for targeted variant analysis of the MPL gene. A pathologist or other qualified health care professional analyzes the data and composes a report.

Clinical Example (81339)

A 55-year-old female presents to the physician with episodic transient ischemic attacks and was found to have a markedly elevated platelet count. The patient was referred to a hematologist/oncologist, who ordered FISH testing for BCR-ABL1, molecular testing for JAK2, MPL W515, and CALR mutation testing, and a bone marrow biopsy. BCR-ABL1, JAK2, MPL W515, and CALR testing was negative, and the bone marrow biopsy showed increased numbers of enlarged megakaryocytes. The physician ordered MPL exon 10 sequence analysis to identify a clonal mutation to establish the diagnosis of essential thrombocythemia.

Description of Procedure (81339)

Isolate and subject high-quality genomic DNA from whole blood to sequence analysis of exon 10 of the MPL gene. A pathologist or other qualified health care professional analyzes the data and composes a report.

Coding Clarification: Total Laparoscopic Hysterectomy and Laparoscopy With Vaginal Hysterectomy

CPT Assistant, August 2021, Volume 31, Issue 8, page 8

There has been confusion about the difference between a total laparoscopic hysterectomy and a laparoscopy with vaginal hysterectomy, as well as the documentation requirements and the appropriate Current Procedural Terminology (CPT®) codes to report for these procedures. The primary difference between the procedures in this family of codes is the method of detaching the structures rather than the route of structure extraction. This article will provide clarification for correct reporting.

Laparoscopy/Hysteroscopy

58541

Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less;

58542

with removal of tube(s) and/or ovary(s)

(Do not report 58541, 58542 in conjunction with 49320, 57000, 57180, 57410, 58140-58146, 58545, 58546, 58561, 58661, 58670, 58671)

58543

Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g;

58544

with removal of tube(s) and/or ovary(s)

(Do not report 58543-58544 in conjunction with 49320, 57000, 57180, 57410, 58140-58146, 58545, 58546, 58561, 58661, 58670, 58671)

58548

Laparoscopy, surgical, 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

(Do not report 58548 in conjunction with 38570-38572, 58210, 58285, 58550-58554)

58550

Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less;

58552

with removal of tube(s) and/or ovary(s)

(Do not report 58550-58552 in conjunction with 49320, 57000, 57180, 57410, 58140-58146, 58545, 58546, 58561, 58661, 58670, 58671)

58553

Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g;

58554

with removal of tube(s) and/or ovary(s)

(Do not report 58553-58554 in conjunction with 49320, 57000, 57180, 57410, 58140-58146, 58545, 58546, 58561, 58661, 58670, 58671)

58570

Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less;

58571

with removal of tube(s) and/or ovary(s)

58572

Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g;

58573

with removal of tube(s) and/or ovary(s)

(Do not report 58570-58573 in conjunction with 49320, 57000, 57180, 57410, 58140-58146, 58150, 58545, 58546, 58561, 58661, 58670, 58671)

58575

Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed

(Do not report 58575 in conjunction with 49255, 49320, 49321, 58570, 58571, 58572, 58573, 58661)

Laparoscopic hysterectomy codes include total laparoscopic hysterectomy codes (58570-58573), laparoscopy with vaginal hysterectomy codes (58550-58554), and laparoscopic supracervical hysterectomy codes (58541-58544). Each family of codes are subdivided into uteri 250 grams or less and greater than 250 grams and with or without removal of tube(s) and/or ovary(s). These codes, in addition to codes 58548 and 58575, are the entire range of codes that address the laparoscopic approach to hysterectomy. The primary difference between the procedures in this family of codes is the method of detaching the structures rather than the route of structure extraction.

Total laparoscopic hysterectomy includes laparoscopically detaching the entire uterine cervix and body from the surrounding supporting structures and suturing the vaginal cuff. It includes laparoscopically bivalving, coring, or morcellating the excised tissues, as required. The uterus is removed through the vagina or abdomen. Codes 58548, Laparoscopy, surgical, 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, and 58575, Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed, represent procedures also performed via a total laparoscopic hysterectomy approach; however, these procedures are performed primarily for excision of malignancy.

Laparoscopy with vaginal hysterectomy includes laparoscopically detaching the uterine body from the surrounding upper supporting structures. The vaginal portion of the procedure is performed. The vaginal apex is entered. Both the cervix and uterus are detached from the remaining supporting structures. The uterus is removed through the vagina.

Laparoscopic supracervical hysterectomy includes laparoscopically detaching the body of the uterus down to the uterine arteries. The uterine body is separated from the cervix, hemostasis of the cervical stump is achieved, and the endocervical canal is coagulated. The uterine body is laparoscopically removed through the abdomen by bivalving, coring, or morcellating, as required.

Table 1 summarizes the differences between each of these procedures. The information in this table should be used as a guide together with the current version of the CPT code set.

Table 1. Summary of Laparoscopic Hysterectomy Procedures and Codes

CPT Codes		Tube(s) and/or Ovary(ies)	Removal of Cervix	Method of Detachment	Method of Extraction
Total Laparoscopic Hysterectomy
58570	≤ 250 grams	No	Yes	Entire uterine cervix and body via laparoscope	Abdomen or Vagina
58571	≤ 250 grams	Yes	Yes	Entire uterine cervix and body via laparoscope	Abdomen or Vagina
58572	> 250 grams	No	Yes	Entire uterine cervix and body via laparoscope	Abdomen or Vagina
58573	> 250 grams	Yes	Yes	Entire uterine cervix and body via laparoscope	Abdomen or Vagina
Laparoscopic Hysterectomy for Malignancy
58548	unspecified	Yes	Yes	Entire uterine cervix and body via laparoscope with para-aortic lymph node sampling; may also include excision of the vagina	Abdomen or Vagina
58575	unspecified	Yes	Yes	Entire uterine cervix and body via laparoscope; also includes tumor debulking and omentectomy	Abdomen
Laparoscopy With Vaginal Hysterectomy
58550	≤ 250 grams	No	Yes	Upper uterine body via the laparoscope and cervix or lower uterine body through the vagina	Vagina
58552	≤ 250 grams	Yes	Yes	Upper uterine body via the laparoscope and cervix or lower uterine body through the vagina	Vagina
58553	> 250 grams	No	Yes	Upper uterine body via the laparoscope and cervix or lower uterine body through the vagina	Vagina
58554	> 250 grams	Yes	Yes	Upper uterine body via the laparoscope and cervix or lower uterine body through the vagina	Vagina
Laparoscopic Supracervical Hysterectomy
58541	≤ 250 grams	No	No	Uterus from the cervix and surrounding tissue laparoscopically	Abdomen
58542	≤ 250 grams	Yes	No	Uterus from the cervix and surrounding tissue laparoscopically	Abdomen
58543	> 250 grams	No	No	Uterus from the cervix and surrounding tissue laparoscopically	Abdomen
58544	> 250 grams	Yes	No	Uterus from the cervix and surrounding tissue laparoscopically	Abdomen