Hysterectomy, Total Laparoscopic (TLH), +/- BSO (Custom ...

[Pages:18]2011 Procedures Adult Criteria

Hysterectomy, Total Laparoscopic (TLH), +/- BSO (Custom) - UDOH

2011 Procedures Adult Criteria

Hysterectomy, Total Laparoscopic (TLH), +/- BSO (Custom) -

UDOH(1*RIN, 2, 3, 4, 5)

Created based on InterQual Subset: Hysterectomy, Total Laparoscopic (TLH), +/- BSO Version: InterQual? 2010

CLIENT: CPT/ICD9: PROVIDER:

Name Code Name Signature

D.O.B. Facility

ID# Service Date ID# Date

GROUP# Phone#

ICD-9-CM: 68.4, 68.41, 68.49

INDICATIONS (choose one and see below)

100 Endocervical adenocarcinoma in situ by Bx 200 CIN III 300 Adenomatous endometrial hyperplasia with cellular atypia by Bx/D & C 400 Fibroids in premenopausal woman 500 Fibroids in postmenopausal woman 600 DUB in premenopausal woman 700 Postmenopausal bleeding 800 Endometrial cancer by pathology 900 Suspected ovarian cancer 1000 Suspected tubal cancer 1100 Tubo-ovarian abscess 1200 Chronic PID 1300 Endometriosis 1400 Suspected adenomyosis 1500 Chronic abdominal/pelvic pain, unknown etiology Indication Not Listed (Provide clinical justification below)

100 Endocervical adenocarcinoma in situ by Bx [One](6*RIN, 7) 110 Completed hysterectomy acknowledgment form

200 CIN III [All](6*RIN, 8) 210 Diagnosed by Bx [One] 211 Colposcopic Bx 212 Cone Bx

InterQual? criteria are intended solely for use as screening guidelines with respect to the medical appropriateness of healthcare services and not for final clinical or payment determination concerning the type or level of medical care provided, or proposed to be provided, to the patient.

The Clinical Content is confidential and proprietary information and is being provided to you solely as it pertains to the information requested. Under copyright law, the Clinical Content may not be copied, distributed or otherwise reproduced except as permitted by and subject to license with McKesson Corporation and/or one of its subsidiaries.

InterQual? copyright ? 2011 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. Portions modified by Licensee have not been independently authenticated in whole or in part by McKesson. McKesson is not responsible for and hereby disclaims any liability related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.

May contain CPT? codes. CPT only ? 2010 American Medical Association. All Rights Reserved.

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Licensed for use exclusively by Utah Department of Health.

2011 Procedures Adult Criteria

Hysterectomy, Total Laparoscopic (TLH), +/- BSO (Custom) - UDOH

220 Prior conservative surgery [One] 221 Laser conization 222 LEEP/LLETZ/LOOP 223 Cold knife conization

230 8 wks post conservative surgery(9) 240 Completed hysterectomy acknowledgment form

300 Adenomatous endometrial hyperplasia with cellular atypia by Bx/D & C [Both](10) 310 Future childbearing [One] 311 Future childbearing desired [Both] -1 Progestin Rx 8 wks [One] A) 8 weeks B) Contraindicated -2 Hyperplasia with cellular atypia confirmed by repeat Bx/D & C after Rx 312 No future childbearing desired 313 Postmenopausal woman and BSO planned(11*MDR) 320 Completed hysterectomy acknowledgment form

400 Fibroids in premenopausal woman [All](12) 410 Diagnosed by US(13) 420 Findings [One] 421 Abnormal bleeding [Both](14, 15, 16) -1 Vagina and cervix normal by PE -2 Continued abnormal bleeding [One] A) Interferes with ADLs(17) B) Hct < 27%(0.27) / Hb < 9.0 g/dL(90 g/L) unresponsive to iron Rx > 12 wks(18) 422 Uterine size doubled by US w/in 1 yr(19) 423 Ureteral compression by US/IVP 424 Other associated symptoms [One](20*MDR) -1 Pelvic/abdominal pain/discomfort w/o other explanation -2 Urinary frequency/urgency w/o evidence of infection -3 Dyspareunia(21) 430 PAP smear normal w/in last yr(22) 440 Pregnancy excluded [One](23) 441 HCG negative(24) 442 Sterilization by Hx(25) 450 Completed hysterectomy acknowledgment form

500 Fibroids in postmenopausal woman [All](26*RIN)

InterQual? copyright ? 2011 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. Portions modified by Licensee have not been independently authenticated in whole or in part by McKesson. McKesson is not responsible for and hereby disclaims any liability related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.

May contain CPT? codes. CPT only ? 2010 American Medical Association. All Rights Reserved. Licensed for use exclusively by Utah Department of Health.

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2011 Procedures Adult Criteria

Hysterectomy, Total Laparoscopic (TLH), +/- BSO (Custom) - UDOH

510 BSO planned(11*MDR) 520 Diagnosed by US(13) 530 Findings [One]

531 Uterine size doubled by US w/in 1 yr(19) 532 Ureteral compression by US/IVP 533 Other associated symptoms [One](20*MDR)

-1 Pelvic/abdominal pain/discomfort w/o other explanation -2 Urinary frequency/urgency w/o evidence of infection -3 Dyspareunia(21) 540 PAP smear normal w/in last yr(22) 550 Completed hysterectomy acknowledgment form

600 DUB in premenopausal woman [All](27, 28) 610 Abnormal bleeding > 3 cycles(14, 15) 620 Vagina and cervix normal by PE 630 Thyroid disease excluded by Hx/PE/testing(29) 640 Pregnancy excluded [One](23) 641 HCG negative(24) 642 Sterilization by Hx(25) 650 PAP smear normal w/in last yr(22) 660 Sonohysterogram/US negative for endometrial lesion(30, 31) 670 Continued bleeding after Rx [One](32) 671 Age < 35 [Both] -1 Progestin/OCP [One] A) x3 consecutive cycles B) Contraindicated -2 Findings [One] A) Interferes with ADLs(17) B) Hct < 27%(0.27) / Hb < 9.0 g/dL(90 g/L) unresponsive to iron Rx > 12 wks(18) 672 Age 35 [All](33) -1 Endometrium normal w/in last yr [One] A) By endometrial Bx B) By hysteroscopy with D & C -2 Progestin/OCP [One] A) x3 consecutive cycles B) Contraindicated -3 Findings [One] A) Interferes with ADLs(17) B) Hct < 27%(0.27) / Hb < 9.0 g/dL(90 g/L) unresponsive to iron Rx > 12 wks(18)

InterQual? copyright ? 2011 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. Portions modified by Licensee have not been independently authenticated in whole or in part by McKesson. McKesson is not responsible for and hereby disclaims any liability related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.

May contain CPT? codes. CPT only ? 2010 American Medical Association. All Rights Reserved. Licensed for use exclusively by Utah Department of Health.

Page 3 of 13

2011 Procedures Adult Criteria

Hysterectomy, Total Laparoscopic (TLH), +/- BSO (Custom) - UDOH

680 Completed hysterectomy acknowledgment form

700 Postmenopausal bleeding [All](34) 710 BSO planned(11*MDR) 720 Vagina and cervix normal by PE 730 HRT [One] 731 Continued abnormal bleeding after change in/discontinuation of HRT(35) 732 HRT contraindicated/refused(36) 740 Endometrium normal w/in last 4 months [One] 741 By hysteroscopy with D & C 742 By endometrial Bx and transvaginal US 750 PAP smear normal w/in last yr(22) 760 Completed hysterectomy acknowledgment form

800 Endometrial cancer by pathology [Both](37, 38) 810 BSO Planned [One] 811 Premenopausal woman and BSO planned(39) 812 Postmenopausal woman and BSO planned(11*MDR) 820 Completed hysterectomy acknowledgment form

900 Suspected ovarian cancer [All](40) 910 BSO planned(11*MDR) 920 Diagnosed by [One](41) 921 US 922 CT/MRI 923 Laparoscopy 930 Completed hysterectomy acknowledgment form

1000 Suspected tubal cancer [All](40) 1010 BSO planned(11*MDR) 1020 Diagnosed by [One](42) 1021 US 1022 CT/MRI 1023 Laparoscopy 1030 Completed hysterectomy acknowledgment form

1100 Tubo-ovarian abscess [All](43) 1110 BSO planned 1120 Diagnosed by imaging [One]

InterQual? copyright ? 2011 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. Portions modified by Licensee have not been independently authenticated in whole or in part by McKesson. McKesson is not responsible for and hereby disclaims any liability related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.

May contain CPT? codes. CPT only ? 2010 American Medical Association. All Rights Reserved. Licensed for use exclusively by Utah Department of Health.

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2011 Procedures Adult Criteria

Hysterectomy, Total Laparoscopic (TLH), +/- BSO (Custom) - UDOH

1121 US 1122 CT/MRI 1130 HCG negative(24) 1140 Worsening Sx/findings [Both] 1141 During IV Abx Rx 1142 Sx/findings [One]

-1 Pelvic pain -2 Abdominal tenderness -3 Persistent adnexal mass -4 Temperature > 100.4 F(38.0 C) -5 WBC 12,000/cu.mm(12x109/L) 1150 Completed hysterectomy acknowledgment form

1200 Chronic PID [All](44, 45)

1210 Pelvic pain

1220 Acute PID 2 episodes by Hx & PE

1230 1240 1250 1260

Infection documented 1 episode by positive culture Adhesions/scarring/hydrosalpinx by laparoscopy(46) PAP smear normal w/in last yr(22) HCG negative(24)

1270 Completed hysterectomy acknowledgment form

1300 Endometriosis [All](47, 48) 1310 BSO addressed(49) 1320 Diagnosed by previous laparoscopy(50, 51) 1330 Continued symptoms after Rx [One](52*MDR, 53, 54) 1331 GnRH agonist 8 weeks(55) 1332 Depot medroxyprogesterone/OCP 8 wks 1333 Danazol 8 wks 1334 Contraindicated 1340 PAP smear normal w/in last yr(22) 1350 Pregnancy excluded [One](23) 1351 HCG negative(24) 1352 Sterilization by Hx(25) 1360 Completed hysterectomy acknowledgment form

1400 Suspected adenomyosis [All](56, 57, 58) 1410 Sx/findings [One](59) 1411 Pelvic pain(60)

InterQual? copyright ? 2011 McKesson Corporation and/or one of its subsidiaries. All Rights Reserved. Portions modified by Licensee have not been independently authenticated in whole or in part by McKesson. McKesson is not responsible for and hereby disclaims any liability related to any such modifications and their inclusion herein does not imply endorsement by McKesson of modifications.

May contain CPT? codes. CPT only ? 2010 American Medical Association. All Rights Reserved. Licensed for use exclusively by Utah Department of Health.

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