The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on Laparoscopic hysterectomy (including laparoscopic total hysterectomy and laparoscopically assisted vaginal hysterectomy) for endometrial cancer.

Description

Endometrial cancer is cancer of the lining of the womb (uterus), known as the endometrium. The most common symptom is abnormal bleeding from the vagina. Surgery for endometrial cancer usually involves the removal of the uterus (hysterectomy). A laparoscopic hysterectomy is carried out through several small incisions in the abdomen (‘keyhole’ surgery), with the aid of an internal telescope and camera system (laparoscope).

Coding recommendations

Laparoscopic hysterectomy (LH):  

Q07.4 Total abdominal hysterectomy NEC

Includes: Hysterectomy NEC

Y75.2 Laparoscopic approach to abdominal cavity NEC

Note: If the clinical record is more specific, then another code may be appropriate from category Q07.- with the addition of Y75.2

Laparoscopic Vaginal Hysterectomy (LVH):

Q08.9 Unspecified vaginal excision of uterus

Includes: Vaginal hysterectomy NEC

Y75.2 Laparoscopic approach to abdominal cavity NEC

Note: If the clinical record is more specific, then another code may be appropriate from category Q08.- with the addition of Y75.2

Laparoscopically Assisted Vaginal Hysterectomy (LAVH):

Q08.9 Unspecified vaginal excision of uterus

Includes: Vaginal hysterectomy NEC

Y75.1 Laparoscopically assisted approach to abdominal cavity

Note: If the clinical record is more specific, then another code may be appropriate from category Q08.- with the addition of Y75.1

In addition an ICD-10 code from category C54.1Malignant neoplasm of endometrium orC79.8 Secondary malignant neoplasm of other specified sites is assigned.

Your responsibility

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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