4. Anatomy
•Two kidneys (filters)
•Renal pelvis/one per
kidney (funnels urine
into ureters)
•Two ureters (to bladder)
•One bladder (storage)
•One urethra (exit)
•Nephro = kidney
•Renal = related to
kidney
•Pyelo = renal pelvis
5. Anatomy
•Kidneys
• Retroperitoneal (behind the peritoneal cavity)
• Right kidney
• Liver is Superior and anterior to the right kidney
• 12th thoracic vertebrae
• Left kidney
• Contact with spleen, pancreas and stomach
• Contact with the 11th rib
• Andrenal glands sit on top of the kidneys
6. Anatomy
•Diseases of Kidneys & Ureters
• Atrophic kidney
• Horseshoe kidney
• Kidney may be found in the pelvis
• Double ureters
•Ureters – muscular tubes extending from the renal
pelvis to the bladder
• Retroperitoneal
• Attach to the bladder
7. Anatomy
•Stones (syn. Calculi, nephrolithiasis, or kidney stones)
• Junction of ureters and renal pelves (pl.)
• Where ureters cross the brim of the pelvic inlet
• Where ureters pass through the wall of the bladder
8. Anatomy
• Bladder
• Hollow muscular viscus
• Walls of the bladder are composed of muscle
• As urine fills the bladder, stretch receptors in the muscle wall
respond
• With relaxation, urine passes through the sphincter into the
urethra and outside the body
• Male – urine left in the urethra is ejected by contraction of
muscles located in the perineum
• Female – urethra is fairly short, explains why females more
easily get bladder infections
9. Anatomy – Male Reproductive
• Testicles (sperm production, contained in scrotum)
• Duct system (transport sperm)
• Epididymis
• Vas deferens
• Accessory glands (contribute to ejaculate)
• Seminal vesicles
• Prostate gland
• Penis
• shaft
• glans
• prepuce
10. Procedures in CPT
50010-53899
•Arranged by location/procedure type
• Incision, excision, repair, etc.
•Bilateral vs. Unilateral
•Operating Microscope (69990) may be separate
•Surgical endoscopy always includes diagnostic
endoscope
11. Kidney Procedures
•Incision – All incision procedures performed as
inpatient services
• “otomy”
• Nephrotomy = incision of kidney
• Pyelotomy = incision of renal pelvis
• Nephrolithotomy
• Incision to remove calculi
• Percutaneous removal of calculi (50080-50081)
• Nephrostomy tract
12. Kidney Procedures
•Excision – performed as inpatient services
• “-ectomy”
• e.g., nephrectomy
• Radical
• Supporting or adjacent structures
• Areas of lymph nodes are taken
• Ablation
14. Kidney Procedures
•Repair
“-orrhaphy” “-pexy” “-ostomy”
• Inpatient only
•Laparoscopy
•Code by procedure
•Endoscopy
•Performed through natural or created opening
• eg, renal endoscopy
15. Kidney Procedures
•Lithotripsy - Crushing of calculi (stones)
•Percutaneous ablation of renal tumors Cryotherapy for
renal tumors
16. Ureter Procedures
•Introduction
•Repair (eg, for stricture, inflammation, injury)
• Revision of urinary-cutaneous anastomosis
Laparoscopy
•Endoscopy - Examination of renal and ureteral
structures
23. Urethral Procedures
• Excision
• Total excision of urethra w/ cystostomy
• Female specific (53210)
• Male specific (53215)
• Excision of diverticulum
• Female (53230)
• Male (53235)
• Excision of Cowper’s gland(53250)
• Male specific
24. Urethral Procedures
• Repair (53400-53520)
• Urethroplasty
• Type of repair
• Gender
• Sling for incontinence (53440-53442)
• Male specific
• Urethrorrhaphy
• Female (53502)
• Male (53505-53515)
31. Prostate Procedures
•Biopsy (55700)
• w/ imaging guidance (76942 in addition)
• Both professional (26) and technical (TC) components
•Excision (55801-55845)
• Code by approach, lymph node involvement
•Other procedures (55870-55899)
• treatments for malignancy
32. Male Reproductive Procedures
•55920 Placement of needles or catheters into pelvic
organs and/or genitalia (except prostate for
subsequent interstitial radioelement application
36. Female Genital Procedures
•Surgery (56405-58999)
• Arranged by anatomy “outside to inside”
• Terms used to describe external female genitalia
• Perineum
• Vulva
• Pudenda
• Introitus
• Consider terminology to determine procedure
• -ectomy = removal
37. Female Genital Procedures
•Vulva (56405-56821)
•Vagina (5700-57426)
• 57022
• Only CPT® code related to obstetrical complications NOT in
labor/delivery section
•Cervix Uteri (57452-57800)
• Os = opening of cervix
39. Female Genital Procedures
•Endoscopy
• Inspection of cavity/hollow organ using a scope
• Laparoscopy = examination of abdominal cavity
• Surgical Endoscopy Always Includes Diagnostic
Endoscopy
40. Female Genital Procedures
•Hysterectomy
• Total
• Removal of fundus + cervix
• TAH = removed through abdomen
• TVH = removed through vagina
• Partial
• Removal of fundus (cervix remains)
• LSH (Laparoscopic surpacervical)
42. Female Genital Procedures
•All Maternity Care and Delivery services would be
performed in an inpatient setting and training
provided as part of inpatient
Editor's Notes
The urinary system consists of two kidneys, right and left; two ureters, right and left; bladder; and urethra in the female and the penis in the male. Kidneys are important excretory organs. This system is often referred to as either the renal or urological system. Kidneys eliminate urea, the chief end product of nitrogen metabolism, formed by the liver in the amount of about 32 gm a day. Besides excess water, electrolytes, waste including toxins, and drugs are eliminated from the body via the urinary system. Kidneys serve a vital role in regulating the excretion of water and electrolytes maintaining the normal volume and composition of body fluids. Kidneys also play a major role in regulation of acid-base balance, regulation of blood pressure, and regulation of red blood cell (RBC) production. Blood enters the kidneys from the renal arteries through the renal pelvis area of the kidney, immediately breaking up into many small branches ending in capillaries. This functional unit of the kidney is the nephron, where materials are reabsorbed, urine is made and channeled into collecting tubules emptying into calyces (singular – calyx), which then empty into the renal pelvis of the kidney. Ureters carry urine to be collected in the urinary bladder for temporary storage until it is eliminated through the urethra to the outside. Under normal conditions the bladder holds up to 500 cc of urine; under abnormal conditions, much more than this.
The kidneys and ureters are subject to several disease conditions and developmental anomalies. One kidney may be atrophic or the inferior ends of the kidneys may be fused (called a horseshoe kidney). A kidney may be found in the pelvis; ureters may be double. These possible anomalies are reminders to the surgeon to always be aware of the location of these structures, particularly, the ureters. An example of this is in female surgery, the ureter passes within 1.5 cm of the uterine artery; the gynecologist (GYN) surgeon performing a hysterectomy locates the ureter so as not to damage it in an unrelated procedure.
Ureters are muscular tubes extending from the renal pelves to the bladder. They are retroperitoneal (behind the peritoneum) running along the back of the abdomen to the pelvis to attach posteriorly to the bladder. Ureters are long, about 10 to 13 inches (25-33 cm), not rigid and about a quarter of an inch (1 cm) in diameter.
Stones (calculi, nephrolithiasis, or kidney stones) form in the urine and can lodge anywhere from the kidneys to the bladder. Common sites for stones in the ureters are at the junction of the ureters and renal pelves, where the ureters cross the brim of the pelvic inlet, and where ureters pass through the wall of the bladder. Stones cause significant pain and may damage kidneys.
The bladder is a hollow muscular viscus located behind the pubic bone when empty. As it fills, the bladder rises anteriorly and superiorly and can extend as high as the umbilicus. The walls of the bladder are composed of muscle. As urine enters the bladder, it is prevented from entering the urethra by contraction of a sphincter (or circular muscle). As the bladder fills, stretch receptors in the muscle wall respond to a degree that a desire to void is elicited. With relaxation, urine passes through the sphincter into the urethra and outside the body. Abdominal muscles can aid this process by increasing intra-abdominal pressure. At the end of micturition (desire to urinate) the sphincter closes.
In the male, any urine left in the urethra is ejected by contraction of muscles located in the perineum .
The male genital system includes external organs, the penis, and scrotum which contain the testes; accessory glands include seminal vesicles and prostate, and the ducts (epididymis and vas deferens). The penis carries urine through the urethra to the outside and it is the male organ of intercourse (copulation). The body (shaft) contains three columns of erectile tissue; the tip is the glans penis and is pierced by the urethra. The loose skin covering the penis forms a cuff around the glans called the foreskin or prepuce. Male circumcision is removal of all or part of the prepuce exposing most or all of the glans. When not stimulated, the penis is flaccid. Erection occurs as the columns of the penis fill with blood and the erectile bodies become enlarged and rigid. Ejaculation is release or expulsion of semen through the external urethral orifice to the outside. Orgasm is the pleasurable sensation occurring at the height of sexual stimulation.
The testes (sing. – testis) are oval shaped, about 2 inches in length, and 1 inch in diameter. Testes produce and store sperm and are an endocrine organ secreting male sex hormones (androgens) into the blood. Spermatozoa (sperm) are produced and mature in seminiferous tubules and enter the epididymis. The epididymis is an elongated structure on the posterior surface of the testis. New sperm are transported to the epididymis and stored until mature. Seminal vesicles (or gland) lie between the bladder and rectum; a thick fluid mixing with sperm is secreted. At the time of ejaculation, sperm enter the vas deferens. The vas deferens (or ductus deferens, or sperm duct) joins the duct of the seminal gland to form the ejaculatory duct. Male sterilization (vasectomy) is a deferentectomy meaning part of the vas deferens is ligated or excised via an incision in the scrotum. This effectively prevents sperm from joining fluid from the seminal vesicles, prostate, and bulbourethral glands.
The scrotum is a pendulous sac containing the testis, epididymis, and ductus deferens holding testicles outside of the body. Temperature cooler than the body is important is sperm production. When exposed to cold, the scrotum retracts or shrinks pulling closer to the body; warm temperatures result in the scrotum expanding away from the body to lose body heat.
The prostate (not prostrate, look both words up!) is a walnut sized gland inferior to the neck of the bladder and surrounding the urethra. It is a combination of muscular and glandular tissue. An enlarged prostate can block or impede urine flow. Location of the prostate close to the rectum is important clinically – an enlarged prostate can be palpated by a finger placed in the rectum through the anal canal, called rectal exam.
CPT® - The Urinary System section begins with kidney and list codes for procedures on the kidney, ureter, bladder, and urethra. Each section has subsections for incision, excision, repair, and other procedures. You will want to make sure you read the description of the codes carefully and watch for codes specifically stating when a procedure is unilateral or bilateral. There are a couple of other overall rules to remember. When an operating microscope is used for a procedure, it should be reported separately. Also remember that when a diagnostic endoscopy is performed with a surgical endoscopy, it is always considered inclusive to the surgical endoscopy. It is not reported separately.
Incision codes report exploration, nephrostomy, drainage, nephrolithotomy, and pyelotomy services. If a patient’s condition is unknown, a renal exploration is performed. Nephrotomy is excision into the kidney and may be used to explore the kidney. Nephrostomy is an opening into the renal pelvis communicating with the exterior of the body; most often, a tube is placed. The urinary system is a dynamic system. The kidneys will continue to make urine even if a stone blocks the ureter. When the system is blocked, urine will back-up unless drained some other way. A nephrostomy serves to drain urine out of the body. Nephrolithotomy is removal of a kidney stone; remember litho-, calculus, and stone all describe the same thing. Percutaneous is from the outside, without an open incision. Percutaneous nephrostolithotomy or pyelostolithotomy can involve use of endoscopy, lithotripsy, stenting, or basket extraction to remove a stone up to 2 cm; over 2 cm. Pyelotomy is incision into the pelvis of the kidney. Open procedures to remove stones are performed in the inpatient setting only.
Excision codes report biopsy, nephrectomy, and removal of a cyst. The codes are listed by approach, percutaneous, or open incision. Nephrectomy is removal of all or a portion of a kidney using an incision. Laparoscopic nephrectomy is reported with 50543, 50545-50548.
The only procedure in this subsection covered in the outpatient hospital and ASC setting is 50200 Renal biopsy; percutaneous, by trocar or needle.
Introduction codes in the kidney include aspiration catheters, injections for radiography, guides, and tube changes. In this case, introduction is a nice way of saying insertion. Codes 50382-50384 are percutaneous procedures for removal or replacement of ureteral stents. These codes include radiological supervision and interpretation and report unilateral procedures. Reminders are given to use modifier 50 for bilateral procedures. Listed in 50385-50386 are codes for transurethral (through the urethra) approach for removal or replacement of ureteral stents. Again, this includes radiological supervision and interpretation. Fortunately, these codes include the symbol for moderate sedation, as well. To report the removal and replacement of externally accessible transnephric ureteral stent, which requires fluoroscopic guidance, use 50387. This series of codes contain numerous parenthetical notes with information about modifier use and reporting—read these instructions carefully when coding using this code range.
Repair codes include pyeloplasty, which is plastic repair; nephrorrhaphy, remember –rrhaphy is the suffix for sewing or suturing; and closure of fistula. The codes in this section are considered inpatient only procedures.
Laparoscopy codes are often abbreviated “scope.” As in many, if not all areas of CPC® diagnostic laparoscopy is included in surgical laparoscopy; they are not reported separately. Diagnostic laparoscopy only in this area is reported with 49320. The procedures in this subsection are not covered in the ASC. Radical nephrectomies and complete nephrectomies are only performed in the inpatient setting.
Endoscopy codes report less invasive kidney procedures. Nephrostomies and pyelostomies report procedures where the endoscope is going through an established opening between the skin and kidney. Codes 50570-50580 report nephrotomies or pyelotomies in which the endoscope is placed through a small incision in the kidney or renal pelvis.
Lithotripsy is a non-invasive procedure for treating kidney stones using shock waves to break them up; they are then passed. Ablation of renal tumors is listed with radiofrequency and cryotherapy.
Introduction category codes report procedures of injection, manometric studies, and the changing of tubes or stents. Code 50684 is an injection procedure to look at the renal collection system. Many of these codes are inpatient only so the addenda to the final rule should be checked.
Repair codes report numerous procedures for the repair of the ureter. The only code in this subsection allowed in the outpatient setting is 50727.
There are only a few laparoscopic codes on the ureter. Like kidneys, ureters get calculi (stones). A laparoscopic ureterolithotomy is the removal of a calculus from the ureter. This procedure is not covered in the ASC.
With endoscopic procedures, the renal and ureteral structures are examined with an endoscope passed through an established opening between the skin and ureter. A guidewire is inserted, the ureterostomy tube is removed, and the endoscope is entered into the kidney or renal pelvis. This procedure usually is performed with local anesthesia. The codes are selected based on the approach (through an established ureterostomy or through a urotomy), and by the procedure performed through the endoscope.
Bladder is a large section. Again, as with other sections, incision, removal, and excision are listed. Also, distinctive services for the bladder such as urodynamics are listed. The Incision category contains codes for insertion of radioactive material or destruction of intravesical lesion as well as removal of stones. A lithotomy is the surgical removal of calculi; cysto means bladder. Code 51050 is a cystolithotomy, the removal of calculus without vesicle neck resection. These three removal category codes, 51100-51102, represent the aspiration of the bladder and are selected based on the method.
Excision codes report excision of an urachal cyst or sinus. An urachal cyst may become infected with the potential to rupture and calls for prompt medical attention. This category contains a range of cystotomy and cystectomy codes. Cystotomies performed to perform a simple excision of the vesical neck (internal orifice between the bladder and the ureter) or procedure for ureterocele (dilation of the ureter) are covered in outpatient facility and ASC.
Cystectomy (bladder removal) is designated as partial or complete. These procedures are performed in an inpatient setting.
Introduction category lists codes for injection, insertion, and instillation procedures. Injection codes are for urethrocystography. Radiological supervision and interpretation is reported in addition to the injection procedures. Insertion of bladder catheters is reported based on whether the catheter is non-dwelling, temporary, indwelling, or complicated. These are the codes used for temporary catheters. These codes are most often included when other procedures are performed and are not coded separately. These codes are reported only when performed independently and shouldn’t be reported when catheter insertion is an inclusive part of another procedure. Code 51720 is for the instillation and retention time. Instillation is performed for bladder cancer. An anticarcinogenic agent is instilled into the bladder using a catheter and is retained in the bladder for a period of time. There are a series of instillations in a course of treatment.
Urodynamics pertain to the motion and flow of urine. Tests examine functional disorders of the lower urinary tract (bladder and urethra). Urodynamic codes include supplies, instruments, and equipment necessary to conduct the tests. 51725 and 51726 are for the bladder. 51736 and 51741 are for studying the emptying of the bladder.
Repair codes for bladder repair, bladder and urethra repair, urethropexy for SUI, and closure of fistulas. Colposuspension is a repair procedure for SUI. Sling procedures also can be used to support and elevate the ureterovesical junction, where the urethra joins the bladder. Other procedures include Marshall-Marchetti-Krantz (MMK), Burch and paravaginal repair. These procedures are reported with 51840 for a simple repair and 51841 for a complicated repair, which would include a secondary repair of the bladder. These two procedures are inpatient only procedures.
The urethral sling and suspension may also be performed laparoscopically and reported with 51990 or 51992. 51990 is used when they suture it up and 51992 for when a sling is used.
Cystourethroscopy codes are bundled endoscopic procedures. Be sure you read the details of each description in this category before assigning the code. The endoscopy codes are coded by location.
The only procedure in this subsection covered in the ASC is the sling operation for stress incontinence.
Excision category includes biopsies, lesion excision, and fulguration (destruction by means of a high-frequency electric current). Marsupialization, creating a pouch, of urethral diverticulum is reported with 53240 on a male or female. Urethrectomy is surgical removal or the urethra in a female and for male. If there is only a tumor and the urethra wasn’t removed, report 53220. Cowper’s gland (bulbourethral gland) is located beneath the prostate; excision is reported with 53250.
Repair of the urethra may be called urethroplasty, which is a plastic repair and may be done in stages with different codes for the stages. Sling operation for male incontinence is 53440 and 53442 is removal or revision of the sling. Urethrorrhaphy is suture of the urethra and are four codes, 53502 for a female and 53505-53515 for a male.
Manipulation codes report dilation of the urethra, and are based on gender and depend on whether the procedure is initial or subsequent.
The Male genital system is divided into nine anatomical subheadings. Many of these sections are very short and will not be covered here in detail.
The Penis subsection is covered in codes (54000-54450). The Incision category, there are significant parenthetical instructions. Code 54015 is Incision and drainage of penis, deep. Remember, there are also incision and drainage (I&D) codes in the Integumentary System. The Destruction category is for the destruction of lesions of the penis. To select the appropriate code, you first select whether it is simple or extensive; then, select the method of destruction. The Excision category contains codes for biopsy, removal of foreign body, amputation, circumcision, etc. Code 54100 Biopsy of penis; (separate procedure) has a parenthetical designation as a separate procedure. There are four amputation codes, the code selection based on whether amputation is partial, complete, or radical. Circumcision has been previously discussed. Codes are selected based on the method and age of the patient. Make sure you pay attention to the parenthetical notes here. The introduction codes are used for various injection procedures and tests. The repair codes comprise the largest number of codes in the Penis subheading and describe various repairs made to the penis. Penile prosthesis codes describe insertion, removal, or repair of penile implants.
The Male genital system is divided into nine anatomical subheadings. Many of these sections are very short and will not be covered here in detail.
The Penis subsection is covered in codes (54000-54450). The Incision category, there are significant parenthetical instructions. Code 54015 is Incision and drainage of penis, deep. Remember, there are also incision and drainage (I&D) codes in the Integumentary System. The Destruction category is for the destruction of lesions of the penis. To select the appropriate code, you first select whether it is simple or extensive; then, select the method of destruction. The Excision category contains codes for biopsy, removal of foreign body, amputation, circumcision, etc. Code 54100 Biopsy of penis; (separate procedure) has a parenthetical designation as a separate procedure. There are four amputation codes, the code selection based on whether amputation is partial, complete, or radical. Circumcision has been previously discussed. Codes are selected based on the method and age of the patient. Make sure you pay attention to the parenthetical notes here. The introduction codes are used for various injection procedures and tests. The repair codes comprise the largest number of codes in the Penis subheading and describe various repairs made to the penis. Penile prosthesis codes describe insertion, removal, or repair of penile implants.
For the Testis subsection, remember orchi means testis. The Excision category includes biopsy, excision, and orchiectomy. There are two biopsy codes: needle or incisional. Both of these procedures are designated as separate procedures. Orchiectomy codes are selected by whether the procedure is simple, partial, or radical. Repair codes include codes for orchiopexy. Orchiopexy is the surgical procedure to move an undescended testicle into the scrotum and fix it there.
Prostate is next. This section is grouped by Incision, Excision, Laparoscopy, and Other Procedures. Prostatitis, benign prostatic hypertrophy (BPH) and cancer are common conditions of the prostate. Treatment of these conditions is based on the degree of prostate enlargement and the severity of symptoms.
Code 55700 Biopsy, prostate; needle or punch, single or multiple, any approach is commonly performed. This is because it is common for the prostate to be enlarged. Enlargement can present challenges in voiding, but, in most instances, it does not mean cancer. Prostate cancer is usually slow growing and can be monitored with PSA levels. Other codes in this section report other types of biopsies.
There are parenthetical instructions at the beginning of the Excision section. All of the codes listed are open procedures, not transurethral. Code 55840 Prostatectomy, retropublic radical, with or without nerve sparing is an involved procedure most likely performed for cancer. The following code, 55842, is all of the above, plus lymph node biopsy. Following this (55845 Prostatectomy, retropublic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes) is a step even further. These three codes demonstrate the progressive nature of procedures becoming more radical. These are considered inpatient only procedures.
The Laparoscopy section contains one code with a reminder that surgical laparoscopy always includes diagnostic laparoscopy. Other procedures lists five codes. Cryosurgical ablation of the prostate is ablating (destroying) prostate tissue using extreme cold.
The reproductive system codes are used to report placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application.
Vagina – passageway from the uterus through the cervix to the outside for menses. It is the birth canal and where sperm are deposited during intercourse.
Uterus – situated between the bladder and rectum, it resembles a flattened pear and is the size of a clenched fist. The upper portion is the body or corpus; the lower portion or opening is the cervix. The lining of this amazing organ is glandular, shedding the lining cells monthly as menses. During pregnancy, the placenta adheres in the cavity to the glandular uterine wall; as the baby grows, the uterus stretches to accommodate 7–8 lbs (or more).
Cervix – the lower part and opening to the uterus; it serves to protect the internal female organs from infection. During labor this amazing organ can stretch from pin-hole diameter to 10 cm allowing a baby to fit through.
Fallopian tubes, tubes, or oviducts – about the caliber of a drinking straw and 3–5 inches in length, the tubes are the conduit for an egg from the ovary, and for the sperm from the vagina through the cervix and uterus, into the tube. Fertilization of the egg by a sperm occurs in the tube.
Ovaries – almond shaped and the size of a small plum, the ovaries store ovum or eggs to be released at ovulation. At birth, a female has all of the eggs in her ovaries that she will ever have. Through the monthly cycle, an ovum matures under hormonal control; at ovulation, the egg is released from the ovary through the fimbria (end portion of the tube) into the tube.
The external female genitalia or vulva includes the mons pubis, labia (majora and minora), hymen, Bartholin’s glands, and clitoris. Also found in this area is the urethra. Some main functions of these organs include:
Urethra – passage of urine from the bladder to the outside
Clitoris – principal female erogenous organ
Protection of internal genital organs from infections
Opening to vagina for menses and intercourse
The internal female genital organs form a pathway as the genital tract. Organs included in this pathway are the vagina, uterus, cervix, fallopian tubes (oviducts or “tubes”) and ovaries.
Procedure or CPT codes for the female reproductive system are in the code range 56405 through 59899. This includes gynecologic procedures, surgeries and codes for maternity care and delivery. These codes are part of the Surgery Chapter, they are therefore listed from the outside to the inside of the body. The term perineum is frequently used to describe the external female organs bounded by the pubis in the front (anterior), the coccyx in the back (posterior) and the thighs. This term is used frequently in operative reports to describe this area. For example, a Bartholin’s gland abscess is found in the perineum, the operative report could read: “…the patient was positioned, the perineum was prepped and draped in the usual fashion, the Bartholin’s gland abscess was...” Marsupialization is a term used related to the incision and drainage of these abscesses that can be confusing. Marsupialization means the formation of a pouch (root word – marsupial, mammals carrying their young in a pouch), when treating a cyst or abscess. The edges of the cyst sac are sewn to the edges of the external incision so it will heal as a pouch with an opening and not close off to reform another cyst or abscess.
Terms sometimes used interchangeably are vulva, perineum and introitus
The vulva, also commonly called pudenda, is used to describe visible external female genitalia. The folds of skin previously mentioned in the anatomy section, labia majora and minora are part of the vulva. Removal of the vulva is a vulvectomy (partial, radical or complete) and it is often done for cancer of these structures. The vulva is not considered a bilateral structure in CPT. Therefore, a unilateral vulvectomy is a partial vulvectomy because the whole vulva has not been removed, just one side. Traumatic injuries to the vulva usually are related to delivery and are coded in that section.
Procedure codes related to the vagina are similar to codes for the vulva mentioned above. Code 57022 (Incision and drainage of vaginal hematoma; obstetrical/postpartum) is the only CPT code related to obstetrical complications that is not found in the labor and delivery section. There are a surprisingly large number of procedures that can be performed on the vagina. Many of these procedures are related to the after-effects of pregnancy and childbirth. Under the “Repair” section, procedures are listed to fix, repair, tighten or support structures adjacent to the vagina such as the bladder or rectum. During the course of childbirth, a baby “squeezes” through an opening that at one time was difficult to insert a tampon into. Through childbirth and with aging, supporting tissues around the vagina lose strength and can require repair or support. This condition is similar to hernias in other parts of the body. Some of these repairs are open procedures, others involve endoscopy. A good medical dictionary can be an important aid in understanding and coding these procedures.
The cervix, or uterine cervix is an amazing structure. The opening of the cervix is the os. The cervix allows menses out and sperm in. It then supports a growing pregnancy for nine months as the baby, amniotic fluid and placenta become heavier; it then stretches or dilates to 10 cm allowing a baby to fit through and enter the birth canal (vagina). A few short months later, the cervix is closed and able to repeat these processes. Disease conditions related to the cervix are manifested through bleeding, a discharge, or they may be silent. Precancerous and cancerous cells can exist on the cervix for years before any symptoms are present. Cultures, pap smears, colposcopy and biopsies are all useful in diagnosing these problems. Because of the location of the cervix wedged between vital structures, the bladder and rectum; a cancer of the cervix not detected before it spreads, can have very serious consequences.
Corpus uteri refers to the top, fundus or body of the uterus as previously described. The most common and often earliest indication of a problem related to the uterus is bleeding. This bleeding is described as “spotting,” “light flow,” “irregular,” “heavy,” “flooding,” and perhaps more creative terms. The glandular lining tissue inside the uterus is the endometrium, it is surrounded by the muscular wall or myometium making up the bulk of the uterus. Later, during pregnancy, it is the contraction of this muscular wall that pushes a baby through the cervix into the vagina and into the world. In a normal regular menstrual cycle following a period, ovarian hormones stimulate the endometrium lining the uterine cavity, to grow, thicken and prepare for pregnancy. Mid-cycle ovulation occurs with the possibility of pregnancy. When pregnancy occurs with fertilization of the egg by a sperm, about a week later the pregnancy implants in the thickened endometrium and continues to grow under hormonal support. When pregnancy doesn’t happen, menstrual bleeding (the next period), occurs with the shedding of the endometrium and the cycle starts over. Average cycle length is 23 to 35 days. Irregular or heavy bleeding can signal hormonal imbalance or more serious situations such as pre-cancer or cancer. Excision CPT codes related to the uterus range from 58100-58294. Excision can range from an in office biopsy (endometrial biopsy) 58100, removal of part of the uterus (myomectomy – removal of a tumor in the muscle of the uterus) to a hysterectomy 58150-58294 with removal of the whole uterus. D&C (58120) is one of the more common female surgical procedures. D&C stands for dilation (sometimes said and spelled “dilatation”) or stretching open the cervical opening and curetting or scraping out the tissue (endometrium) inside the uterus. This procedure is similar to an endometrial biopsy only, more tissue is removed.
Hysterectomy procedures not requiring endoscopy or laparoscopy are listed in the range 58150-58294. Endoscopic or laparoscopic procedures to remove the uterus are listed in codes 58541-58554 and 58570-58579. There is confusion about the term “total hysterectomy” among patients and even some health care personnel. This is where the earlier discussion about the uterus = fundus + cervix comes in handy. A total hysterectomy means removal of the whole uterus, the fundus + cervix, example 58150. A subtotal, partial or supracervical hysterectomy means removal of the fundus or top portion of the uterus only, leaving the cervix in place, example 58180. Making things a little more confusing can be abbreviations with letters used in medical charts and by medical personnel. A TAH is a total abdominal hysterectomy, a TVH is a total vaginal hysterectomy – both abbreviations specify the entire uterus is removed and they specify the route – through the abdomen or through the vagina.
Now add the laparoscopic procedures – LAVH 58550, 58553 indicates a laparoscopically assisted vaginal hysterectomy, the whole or total uterus is removed vaginally with laparoscopic assistance. LSH 58541, 58543 indicates a laparoscopic supracervical hysterectomy, a partial or sub-total hysterectecomy because the top portion (“supracervical”) of the uterus is removed leaving the cervix in place. LH (laparoscopic hysterectomy) or TLH (total laparoscopic hysterectomy) 58570, 58572 indicate a total hysterectomy done entirely endoscopically.
Here is part of the “key” to all of this; we have been talking about the uterus only, no mention of the tubes or ovaries. Many are confused in thinking that a “total hysterectomy” means uterus + tubes + ovaries are removed. Wrong! The word total refers only to the uterus, not the tubes and ovaries. So, when a patient says, “I am having a partial hysterectomy.” It is important to clarify what structures are being removed, does that statement mean the entire uterus or just the fundus and the cervix is staying. To go on with the abbreviations, a TAH, BSO indicates a total abdominal hysterectomy, bilateral salpingo-oophorectomy. Fortunately the code for TAH and TAH, BSO is the same, 58150. Understanding the above discussion is part of speaking the language of medicine and can help in reading medical records and operative reports.
