Routine cuff fixation after vaginal hysterectomy

Read an original fictional chart, identify the supported facts, and explain your coding workflow.

Chart gym · Original fictional record

Service date: 2026-09-09 · Outpatient professional procedure; cited Medicare NCCI relationship

Use your code books and write your reasoning before opening the walkthrough. This exercise contains no real patient information.

Operative context

Synthetic hospital operative record, September 9, 2026. An adult undergoes vaginal hysterectomy for benign uterine leiomyomas with persistent bleeding. The uterine body and cervix are removed vaginally; the specimen weighs 120 grams. No tube or ovary is removed.

Signed fixation and closure note

The surgeon performs the fixation of the vagina to surrounding tissues routinely associated with vaginal hysterectomy and closes the cuff. The report documents no additional sacrospinous, iliococcygeal or other extensive vaginal suspension dissection and no separate anterior or posterior compartment repair.

Completed anatomy

The uterus and cervix are removed, the adnexa are preserved, and routine fixation and closure complete the operation. The record does not establish a separately performed colpopexy merely because fixation sutures are present.

Procedure worksheet

A draft adds colpopexy based on the word fixation. Compare the actual work with Medicare NCCI’s routine-fixation distinction. The route, specimen weight and preserved adnexa are provided for the authorized hysterectomy-entry lookup; do not invent additional suspension work.

Your coding worksheet

Identify the completed hysterectomy route, organ removal and weight.
Distinguish routine fixation from a separately performed extensive colpopexy.
Evaluate the extra colpopexy line.
Use the supplied operative facts to review the complete current hysterectomy entry.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.

Compare with the worked explanation

The record describes vaginal removal of the uterine body and cervix, weighing 120 grams, with the tubes and ovaries preserved.
Only routine fixation and cuff closure are documented. No additional extensive colpopexy is performed.
NCCI E.10 does not permit routine fixation during vaginal hysterectomy to be reported as a separate colpopexy.
Use the documented route, weight and associated work in the full authorized hysterectomy entry; the sutures do not supply a missing additional suspension procedure.

Reference sections: E.10

Practice the linked chart questions