# How would you code this surgery?



## jdibble (Feb 24, 2011)

Can someone help me with what codes you would use for this surgery?  It was billed out with 51992, 51990, 57240, 57267 & 52000, 57282.  I have been asked to review it for correct codes as this office seems to unbundle quite often. I know the 51990 is wrong and I don't think 57282 is correct either - I was thinking 57267 & 57288:

Operative Report

PROCEDURE:  Anterior colporrhaphy, vaginal extraperitoneal colposuspension (anterior compartment), insertion of mesh for correction of pelvic support defects, urethral suspension with TVT EXACT, cystoscopy.

PREOPERATIVE DIAGNOSES:
1.  Third-degree cystocele.
2.  Second-degree uterovaginal prolapse.
3.  Weakened pubocervical fascia.
4.  Stress urinary incontinence.

POSTOPERATIVE DIAGNOSES:
1.  Third-degree cystocele.
2.  Second-degree uterovaginal prolapse.
3.  Weakened pubocervical fascia.
4.  Stress urinary incontinence.

OPERATIVE PROCEDURE:  Patient was taken to the OR and after general anesthesia placed in dorsal lithotomy position and prepped vaginally with Betadine.  Her bladder was drained off clear urine and a Foley catheter was kept in place and clamped for intermittent drainage during the procedure.  Bimanual exam and inspection revealed a third-degree cystocele with no significant rectocele, second-degree uterovaginal prolapse.  Patient was prepped and draped in sterile manner.  Procedure was begun by placing Allis clamps in the midline along the anterior vaginal vault, the first one just below the UVJ and the second one above the cervix.  The tissue was placed on tension.  Anesthetic solution of 0.25% Marcaine with epinephrine was diluted one-to-one with normal saline was injected into the vesicovaginal space creating hydrodissection of the space.  Approximately 40 cc was used.  A full thickness vaginal incision was made in the midline with cautery.  This then followed incising the vaginal epithelial muscularis and pubocervical fascia.  The vesicovaginal space was then entered sharply and extended laterally using a combination of sharp and blunt dissection leading to the paravaginal and paravesical space.  Blunt dissection was performed along the obturator internus muscle down to the ischial spine along the arcus tendineus to the edge of the iliococcygeus fascia.  This was repeated bilaterally.  Bleeding was noted to be heavier than usual on both sides, particularly on the right side and a 4 x 4 packing was placed.  Dissection was continued up to the ureterovesical junction down to the cervix and tacking suture of 0 PDS was placed at the UVJ and 2 tacking sutures of 2-0 Prolene were placed into the cervical stroma.  Using the Prolift system of trocars, cannulas and retrieval sutures, anterior suspension was accomplished.  Anterior landmarks were identified and marked with a marking pen.  The superior medial notch of the obturator foramen was identified near the level of the clitoris.  The inferior medial notch of the obturator foramen was identified approximately 1 cm medial and 2 cm below the initial marking.  Anesthetic solution was injected at these 2 markings and a 3 cm incision was made at these marks.  Both packings were removed at this time.  Using the trocar, cannula and direct palpation, the trocars were passed through the inferior medial notch, passing through the adductor muscle, obturator externus muscle and piercing the obturator membrane, then guiding the needle down toward the ischial spine behind the obturator internus muscle.  The needle was brought out at the base of the ischial spine through the iliococcygeus muscle.  The tip of the needle was brought out against the finger.  Cannula was deployed against the finger and the trocar was removed.  A retrieval suture was passed on the cannula and worked out of the paravaginal space through the vaginal incision.  The retrieval suture was then held in place for later use.  In similar fashion, the trocar and cannula was passed through the superior medial notch of the obturator foramen and again the cannula was brought out against the finger inside the obturator foramen behind the pubic ramus.  The cannula was deployed and brought out through the vaginal incision.  The retrieval suture was then passed down the cannula and held in place.  This procedure was repeated bilaterally providing four suspensory sutures for colposuspension.  Bleeding which was heavier than normal was noted bilaterally.  At this point a FloSeal was prepared and injected into the paravaginal space bilaterally.  A lap pad was placed into the vagina and the pressure was placed against the lap pad for 5 minutes.  The bleeding was noted to decrease significantly.  The packing was kept in place while cystoscopy was performed.  The bladder was noted to be intact and full flow of indigo carmine dye was noted from both ureters.  The Prolift mesh was then prepared and trimmed as needed both laterally and at the apex.  The graft was brought in the operative field position.  The packing was removed through vagina and the graft was then tied in place with tacking sutures.  The free arms of the graft then delivered through the cannulas using retrieval sutures.  Once the retrieval sutures were brought down in position the mesh was irrigated with gentamicin solution.  The mesh was noted to be lying flat against the bladder.  The anterior colporrhaphy was then completed with approximation of full thickness of the vaginal wall sites using continuous 0-Vicryl.  Final steps of procedure involved placing a tension on the mesh.  Two fingers were placed anteriorly at the pubic ramus and the arms were stretched out and then a protraction was used to release the tension.  The cannula was removed as the pressure was maintained against the arms of the mesh.  This was repeated in similar fashion at the ischial spine to the vaginal fornices.  The arms and the mesh were trimmed below the skin.  Vaginal packing was placed high in the vagina and toward the ischial spines for providing pressure and hemostasis.  The urethral suspension was then begun.  Twenty cc of dilute Pitressin solution and lidocaine was injected into the retropubic space and approximately 5 cc in the periurethral area.  Foley catheter was placed with drainage of minimal clear blue urine.  The UVJ was identified and a 1 cm longitudinal incision was made at the mid urethra.  The vaginal epithelium was then undermined laterally in both directions of the pubic ramus.  The TVT EXACT needle was then introduced and was directed initially towards the patient's right side while the bladder was deviated to the patient's left side using the wire guide passed on the Foley catheter.  The needle was passed through the endopelvic fascia and then dropped down to bring the needle behind the pubic ramus against the pubic bone, then bringing the needle out through the anterior abdominal wall approximately 2 cm lateral to midline.  The needle was advanced to allow passage of the second needle.  The bladder was then deviated to the opposite side and procedure was repeated in similar fashion.  Both cannulas were kept in place while cystoscopy was performed.  Cystoscopy revealed prompt spill from both ureters.  The bladder was noted to be intact with the course of the needle noted to be extrinsic to the bladder.  Fluid was kept in the bladder and the scope was removed.  The cannulas were advanced through the anterior abdominal wall bringing the sling within 1 cm of the urethra.  A hemostat was placed between the urethra and the tape.  With a Crede maneuver, leakage was noted.  The tape was adjusted until there was scant drop of urine at the urethra.  The needles were then removed from the sheath.  The tape was held in position with a clamp while the sheath was slid off the tape.  The tape was irrigated.  The vaginal epithelium was closed with 2-0 continuous Vicryl suture.  The tape was cut below the skin line at the anterior abdominal wall.  All skin incisions at this point were sutured with 4-0 Vicryl interrupted suture.  Steri-Strips applied to all incisions.  The vaginal packing was removed and replaced with 2 vaginal packings tied together and tightly packed into the vagina, directed towards both ischial spines.  Counts were correct.  Estimated blood loss was 250 cc.  Pressure was placed against the packing for additional 5 minutes while the skin sutures were placed.  There was no oozing noted from the suture sites at the end of the procedure.  Procedure was without complication.  Counts were correct.


 I would appreciate all the help I can get along with the rational behind the codes so I can understand the reasons! I usually don't do any GYN coding and I need all the help I can get!

Thanks,


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## Anastasia (Feb 27, 2011)

I would use 57288, 57240, 57267 and 57282. The 52000 is included w/57288. You could also add 57106. These are billable together. Hope this helps.


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## jdibble (Mar 1, 2011)

Thank you Anastasia - this was helpful!  I didn't even see the 57106.


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