# Lap ovarian cystectomy with fulguration of endometriosis



## awest (Aug 30, 2010)

I need some help with this case, I'm not sure if I should just use 58662 and 58558, or if I need other codes for the lysis of the pelvic adhesions,...

Please read and help! Thanks for any input!

PROCEDURES PERFORMED:  Laparoscopic right ovarian cystectomy, left ovarian cystectomy, fulguration of endometriosis, lysis of pelvic adhesions, and biopsy of the left and right ovary.  We did a diagnostic hysteroscopy and also fractional D&C.


ANESTHESIA:  General.

DESCRIPTION OF THE PROCEDURE:  After the patient was prepped and draped in the usual fashion, we placed a Graves speculum into the vagina.  We grasped the anterior lip of the cervix with a single-tooth tenaculum.  We dilated the cervix and then performed hysteroscopy visualizing the endocervical endometrial cavity visualizing the endometrium.  At the internal os, there was a large edematous endometrium on the patient's right side from the posterior aspect of the endometrium wrapping around to the anterior.  There were also some thickened areas of endometrium with some bands of endometrium crossing the endometrial cavity.  We then performed fractional D&C obtaining endocervical followed by endometrium curettings.  We re-curetted after performing second hysteroscopy to assure complete curetting.  There were some still thickened areas, so we re-curetted and then we visualized again and we got adequate thinning of the endometrial cavity and specimen.  We then removed our hysteroscope, placed a HUMI catheter into the endometrium for manipulation of the uterus and laparoscopy ____ [inaudible] proceed laparoscopically.  We made a 1.2 cm vertical incision in the umbilicus with a #11 blade and with the Optiview trocar under laparoscopic visualization placed the trocar into the peritoneal cavity.  Once the position of the trocar was assured, we obtained pneumoperitoneum immediately upon visualizing the pelvis.  We noticed there to be a large right ovarian cyst and the left ovary was adhesed to the cul-de-sac and had what appeared to be an endometrioma as well as endometriosis, which had a dark bloody fluid oozing from it when touched.  There was some scar tissue in the anterior vesicouterine reflection of the peritoneum.  There were also multiple small sites of endometriosis.  We then lysed these adhesions, freed up the left ovary, so we could excise the endometrioma on the left.

After freeing up the adhesions there and releasing the pressure on the vesicouterine reflection of anterior peritoneum, we then performed cystectomy on the right as well as ovarian biopsy on the right, cauterized the cyst wall and the free edges of the opening into the cyst to assure hemostasis.  We irrigated to assure hemostasis.  We fulgurated the areas of endometriosis on the left pelvic sidewall and the left ovary, draining and removing what appeared to be an endometrioma.  We also biopsied the left ovary.  We irrigated the pelvis to assure hemostasis after completing our lysis of adhesions or fulguration of endometriosis, bilateral ovarian cystectomy, and biopsy of both ovaries as well.  Hemostasis was observed.  We then removed all instruments, reduced the pneumoperitoneum, sutured the fascial incision with interrupted 0 Vicryl suture.  We closed the skin with a 4-0 undyed Vicryl sutures in a subcuticular stitch.  HUMI catheter was removed.  The patient was then awakened from anesthesia and sent to recovery room in a stable condition.  Estimated blood loss was less than 10 cc.  There were no complications.  Specimens sent to pathology include biopsy of right and left ovary.  The patient will be observed in recovery room and once stable, will be discharged to home.


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## crickett (Aug 30, 2010)

Check out 49321 and see what you think...it's not bundled with 58662


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## preserene (Aug 30, 2010)

58662-22, 58588 -59


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## preserene (Aug 30, 2010)

58662- Lap surgical; with excision of lesionof the ovary.......
 Why modifier 22- Increased proced service by way of more work with biopsy both ovaries,
 endometrioma ( pelvic endometriosis) adhesion release from the pelvic wall  and adnexal tissues and excision of endomerioma- all increased procedural work and time.
58588- Hysteroscopy Surgical;............with or without D&C. There were intra uterine syneche[ ( Criscrossing bands in side the uterine cavity) which are necessarily to be removed if you want  effective and complete D& C, which by itself has a codeset (description) 58589]  But this was not done separately andso it can be appended with a modifier of distinct procedural service- 59. this is considered and distinguised as a separate procedure of its own. 
More over the hysteroscopy and curetting done twice to recheck the completeness of the first procedure

 You cannot give 58589 alone because it does not have the component of D& C
 so my openion is : 58662- 22, 58588-51,59 ;   but  I feel there has to be some rearrangement of the codes i gave!!
let us see how others opt for.


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## awest (Aug 31, 2010)

Thank you so much for the input. It has been very helpful!


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