Coding and Billing Guidelines

Recent technological advances in gynecologic surgery have facilitated an increase in vNOTES procedures. This has created uncertainty regarding appropriate coding and billing procedures. As a relatively new technique, and without any official guidance from CMS and the AMA, some authorities have opined that the codes for TVH (58260-58294) are the most appropriate hysterectomy codes. However, others have favored the use of the LAVH codes (58550-58554). To further complicate the matter, other procedures are being performed using a vNOTES technique for which there is no similar “vaginal” code. These procedures include appendectomy, oophorectomy, cystectomy, salpingectomy, etc.

Laparoscopy involves placing instruments into the abdominal cavity using a lens and special instruments to work through small openings in the peritoneal cavity after filling the cavity with an inert substance such as carbon dioxide gas. Traditionally, these incisions (ports) were placed through the anterior abdominal wall and usually initially through an embryonic “natural orifice” (the umbilicus). However, as the need arose, surgeons began “moving” the entry point to alternate locations such as subcostal or lateral locations. The location of the placement of the laparoscopic ports does not alter the definition of the technique of “laparoscopy” as it is the same at its essence. That is, laparoscopy involves the use of a lens and instruments controlled outside of the abdomen that effect an action through a port inside of the insufflated abdominal cavity.

With vNOTES techniques, a small incision is made into the abdomen through an alternate natural orifice, the vagina: specifically, the anterior and/or posterior cul-de-sac. A port is placed into the abdominal peritoneal cavity. The cavity is distended with an inert gas and the lens and instruments are introduced into the cavity where the surgical procedural steps are performed (whether it be a hysterectomy or other procedure). For a hysterectomy, this involves the exact same steps as a laparoscopic assisted vaginal hysterectomy (LAVH).

Because of the surgeon’s initial point of reference, the steps are completed from caudal to cephalad rather than the opposite. The procedural steps remain the same, however. The uterus is removed from the vaginal opening and then the incision is closed in the exact same manner as the LAVH. Because the surgeon’s time, procedural work, technique, instruments (laparoscope lens, camera, insufflator, energy devices, graspers, etc), supplies (ports, sutures, drapes, prep materials, etc), and staffing are otherwise identical to an LAVH, we suggest that the LAVH CPT codes are the most appropriate hysterectomy codes when performed using a “vNOTES” technique (CPT 58550-58554).

vNOTES refers to placing the initial port in the vagina rather than the umbilicus but otherwise does not designate a different procedure. For this reason, we also recommend standard laparoscopic codes be used based on the equivalent surgical procedural steps rather than the location of the first port (some “vNOTES” surgeons will later place ports into the abdomen to assist if needed). This includes laparoscopic tubal sterilization, salpingectomy, oophorectomy, cystectomy, appendectomy, and any other conceivable equivalents. Furthermore, the technical aspects of each case are otherwise identical, so we do not feel that this requires the use of an unlisted procedure (58999).

After review of AMA, AAPC and ACOG documents, the definition of laparoscopy does not state that the ports must be placed through the abdominal wall but rather that the lens and instruments are placed into the abdominal cavity where the work is to be done. As with other enabling technologies, such as robotically assisted TLH or LAVH, we believe that existing CPT codes for laparoscopic surgical procedures apply.

If the AMA’s CPT Editorial Panel decides to provide a unique set of CPT codes, then we would expect that the body of surgeons who perform vNOTES procedures would be consulted. Currently, there are two official bodies that are devoted to supporting the needs of these surgeons: the International NOTES Society (an international body devoted to the support of NOTES surgeons), and vNOTES USA (a 501c-3 specialty society specifically formed to support the needs of those surgeons who practice in the United States).

Approved by vNOTES USA Society Board of Directors, November 2022