At present, we perform LUAO only in patients who have completed childbearing, although early evidence suggests that pregnancy may be relatively safe after uterine artery occlusion.19,20 More data and longer follow-up are required before LUAO should be offered to all women of reproductive age.
8. Consider single-incision laparoscopic myomectomy
This approach has been touted as offering an improved cosmetic outcome and, possibly, less postoperative pain, although these potential benefits have yet to be demonstrated in a well-designed prospective trial.21
We have performed three cases of single-incision myomectomy for an intramural fibroid and have demonstrated this approach to be feasible (article in press). Barbed suture is especially valuable in single-incision surgery because intracorporeal knot-tying can be more challenging when there is only one incision. However, limitations include:
- a lack of triangulation
- instrument crowding at the umbilicus
- difficulty suturing using traditional or barbed suture.
Choose the right code when you bill for lap myomectomy
Proper documentation is key
Proper documentation is key
Current Procedural Terminology (CPT) offers two coding options when you've performed a laparoscopic myomectomy:
- 58545 (laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas)
- 58546 (laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g).
Which code you submit can, of course, make a difference in how much you're reimbursed: 58545 carries 24.21 relative value units (RVU); 58546, 30.59 RVU. The documentation that you present will, therefore, be key in getting paid for the work you've performed.
First, look at the description of 58545. You have two documentation options:
- You removed between one and four intramural myomas (International Classification of Diseases [ICD-9] 218.1; intramural leiomyoma of uterus) whose total weight was =250 g
- You encountered surface myomas (ICD9 218.2; subserous leiomyoma of uterus) and removed all of them, weight aside.
Second, to bill the higher-paying code (58546), you must clearly document removal of intramural myomas only. Again, your work must meet either of two criteria:
- Total weight of all intramural myomas removed is >250 g
- You removed five or more intramural myomas.
You can determine the total weight of the excised tissue 1) in the operating room, if a scale is available, or 2) from the pathology report. A caution: The tissue that you've removed will shrink after it arrives in pathology, and this shrinkage may make a difference when, for example, fewer than five myomas were removed and their total weight is close to 250 g.
Last, estimating the weight of myomas by ultrasonography before surgery is not considered acceptable documentation of weight by most payers.—Melanie Witt, RN, CPC, COBGC, MA
Ms. Witt is an independent coding and documentation consultant and former program manager, department of coding and nomenclature, American College of Obstetricians and Gynecologists.
Therefore, it may be challenging to apply single-port surgery to more complex pathology, such as very large fibroids and severe pelvic adhesive disease.
Single-incision surgery may offer marginal cosmetic benefit for some patients. When we surveyed our patients informally, however, most of them expressed satisfaction with the cosmetic appearance of peripheral laparoscopic port incisions.
Another potential limitation of single-incision surgery is the cost associated with disposable, articulating instruments and single-port access devices. Although robotic surgery is a feasible approach to both multi-port22,23 and single-port surgery,24 prospective data are lacking, and cost remains an issue. It is possible that future developments in robotic surgery may facilitate suture-intensive, single-incision cases such as myomectomy and sacrocolpopexy. Well-designed prospective trials are urgently needed.