Understanding Bilateral Salpingectomy, also known as Fallopian Tube Removal? This resource provides information on Salpingectomy coding, clinical documentation requirements, and healthcare implications for accurate medical coding and billing. Learn about diagnosis codes related to Bilateral Salpingectomy, including ICD-10 and CPT codes, for proper medical record documentation. Find key details for healthcare professionals involved in coding and billing for this procedure.
Also known as
Salpingectomy and/or oophorectomy
Removal of fallopian tube(s) and/or ovary/ovaries.
Other excision of fallopian tube
Surgical removal of fallopian tube tissue.
Factors influencing health status and...
May include acquired absence of fallopian tubes.
Follow this step-by-step guide to choose the correct ICD-10 code.
Was the salpingectomy performed for sterilization?
Yes
Code Z30.2 (Encounter for sterilization)
No
Was it for ovarian malignancy?
When to use each related code
| Description |
|---|
| Removal of both fallopian tubes. |
| Removal of one fallopian tube. |
| Blockage of one or both fallopian tubes. |
Incorrect coding for bilaterality (e.g., using unilateral code) can lead to underpayment or claim denials. CDI review is crucial.
Insufficient documentation of medical necessity for salpingectomy may trigger audits. Clear indication is required for compliance.
Potential risk of unbundling related procedures or using incorrect bundled codes for fallopian tube removal. Audit target for overpayment.
Q: What are the evidence-based best practices for minimizing complications in laparoscopic bilateral salpingectomy for sterilization?
A: Minimizing complications in laparoscopic bilateral salpingectomy involves meticulous surgical technique and patient-specific risk assessment. Evidence-based best practices include utilizing bipolar energy devices for precise tissue sealing and minimizing thermal spread, confirming adequate visualization of the fallopian tubes and surrounding structures before ligation or resection, and employing careful trocar placement to avoid vessel or bowel injury. For patients with prior abdominal surgery or distorted pelvic anatomy, consider utilizing open or robotic-assisted approaches to enhance surgical access and reduce the risk of complications. Thorough preoperative counseling and informed consent discussions regarding potential risks, including bleeding, infection, and ectopic pregnancy (although rare), are also crucial. Explore how incorporating these practices can improve patient outcomes and surgical efficiency. Consider implementing a standardized surgical checklist to ensure consistent adherence to best practices during laparoscopic bilateral salpingectomy.
Q: How can I differentiate between unilateral and bilateral salpingectomy coding and documentation requirements for accurate reimbursement?
A: Accurate coding and documentation are crucial for appropriate reimbursement after salpingectomy. Unilateral salpingectomy involves removal of one fallopian tube (CPT code 58720), while bilateral salpingectomy involves removal of both fallopian tubes (CPT code 58740). Documentation should clearly specify the laterality of the procedure, the indication (e.g., sterilization, ectopic pregnancy, prophylactic removal due to genetic risk), and the surgical technique employed (e.g., laparoscopic, open, robotic). When performed for sterilization purposes, append modifier -52 to CPT code 58740 if any component of a standard bilateral salpingectomy is not performed. Precise documentation of any intraoperative findings, such as adhesions, endometriosis, or other pelvic pathology, is also essential for accurate coding and justification of additional procedures. Learn more about proper coding guidelines for gynecological procedures to ensure optimal reimbursement and avoid claim denials.
Patient presents for bilateral salpingectomy, also known as fallopian tube removal. Indications for this procedure include elective sterilization, risk reduction for ovarian cancer (particularly in patients with BRCA mutations), ectopic pregnancy, hydrosalpinx, or severe pelvic inflammatory disease. The patient's medical history, including gynecological history, relevant imaging (e.g., pelvic ultrasound, CT scan), and family history of ovarian or breast cancer, were reviewed and documented. Risks and benefits of the procedure, including potential complications such as bleeding, infection, and damage to adjacent organs, were thoroughly discussed with the patient, and informed consent was obtained. Preoperative orders, including NPO status and prophylactic antibiotics, were implemented per standard protocol. The surgical plan for laparoscopic bilateral salpingectomy was reviewed. Postoperative care will include pain management, monitoring for complications such as hemorrhage or infection, and patient education regarding recovery expectations and follow-up. This procedure is coded using CPT code 58720. Relevant ICD-10 codes will be assigned based on the specific indication for the salpingectomy, such as Z30.2 for sterilization, or C56.9 for malignant neoplasm of ovary. The patient's prognosis following bilateral salpingectomy is generally excellent, depending on the underlying indication.