# I am stumped on this one



## mraymond74 (Mar 13, 2009)

I am hoping someone can help me on this one.  I am new to the OB/GYN surgery world. 
I am reading about the bundling and I am not sure how I should code this. If anyone can help me, I would greatly appreciate it!
I have attached a copy of note.  

                                OPERATIVE REPORT

DATE OF OPERATION:   03/05/2009

OPERATIVE REPORT

PREOPERATIVE DIAGNOSES:
1. Symptomatic uterine leiomyoma.
2. Left ovarian cyst.

POSTOPERATIVE DIAGNOSES:
1. Symptomatic uterine leiomyoma.
2. Left ovarian cyst.

PROCEDURES:
1. Total laparoscopic hysterectomy.
2. Lysis of adhesions.
3. Left salpingo-oophorectomy.

ANESTHESIA:  General endotracheal tube anesthesia.

SURGEON:  
ASSISTANT:  

INTRAVENOUS FLUIDS AND URINE OUTPUT:  Per anesthesia record.

ESTIMATED BLOOD LOSS:  100 mL.

FINDINGS:
1. 10 week sized uterus.
2. Extensive adhesions of the bladder to the anterior uterine wall as well as to the right pelvic sidewall.
3. Right ovary was noted to be adhesed to the pelvic sidewall as well as a loop of small bowel and ascending colon densely adherent to the right ovary.
4. The left ovary was noted to have several paratubal cysts and what appeared to be a follicular cyst.
5. The surrounding peritoneum did appear to be somewhat edematous, but normal appearing pelvis otherwise.

DETAILED PROCEDURAL NOTE:  The patient was taken to the operating room where general anesthesia was performed.  She was then placed in the dorsal lithotomy position using Allen stirrups.  Care was taken to assure that the hips and knees were flexed no greater than 90 degrees and the ipsilateral, ankle, knee and hip were aligned to the contralateral shoulders.  The patient was then prepped and draped in the usual sterile fashion.
Attention was first turned to the vagina where a sterile bivalved speculum was placed in the vagina.  The anterior lip of the cervix was grasped with a single-tooth tenaculum and the cervix was gently dilated to allow a VCare manipulator into the uterus.  A medium VCare cup was placed with a balloon occluder below this.  The cervix was seated tightly down into the VCare cup.  The VCare balloon had been filled with 3 mL of fluid.  A tight fit was noted as is appropriate and excellent mobilization of the uterus was noted.  The speculum was removed from the vagina at time of placement of the VCare.
Attention was then turned to the abdomen where, due to the patient's prior surgeries, the left upper quadrant in the midclavicular line just under the last rib was injected with Marcaine and a 5 mm stab incision was then performed.  Veress needle was then inserted without difficulty and utilizing the drop technique and noting low opening insufflation pressures, proper placement was confirmed.  A 5 mm port was then inserted without difficulty and proper placement was once again confirmed with direct visualization.  Surrounding structures were evaluated and no injuries were noted to this area.
The patient was then placed in Trendelenburg position.  The umbilicus was noted to be free without adhesions.  All port sites were injected with Marcaine prior to incision.  A 5 mm stab incision was made in the umbilicus and a 5 mm port was placed under direct visualization.  The camera was then moved to the 5 mm umbilical port.  Right and left ports, 5 mm ports, were placed without difficulty approximately 3 cm superior and 3 cm medial to the SIS spines after careful identification of the inferior epigastric arteries.  Both ports were placed without difficulty.  A 10-12 port was placed on the right side.
Attention was first turned to the to the right side of the uterus where a LigaSure was utilized to desiccate and transect the round ligament followed by the utero-ovarian ligament and tube.  The anterior leaf of the broad ligament was then serially transected down to where the bladder wall adhesions were noted.  The bladder was then carefully dissected free from the sidewall and the right side of the uterus.  The posterior leaf of the broad ligament was dissected in a similar fashion and the right uterine artery was desiccated.  The left side was addressed in similar fashion, again having to dissect the bladder carefully from the anterior uterine wall.
Once the bladder flap was successfully created and the bladder was dissected free from the cervix and anterior vagina and the uterine arteries were assured to be desiccated, they were then transected bilaterally.  Excellent hemostasis was assured.  The VCare cup was palpated and using the Harmonic Ace, the vaginal cuff was entered.  The cervix was then freed from the vagina all the way around by following the VCare cup around serially.  The uterus was then brought down into the vagina where excellent pneumoperitoneum was maintained.
Due to the findings of the right ovarian adhesions, attention was first turned to the left tube and ovary.  The left tube was serially desiccated and transected along the mesosalpinx, until the tube was freed from its pedicles, and was placed carefully down into the vagina.  The left ovary again was noted to have dense surrounding peritoneum which was carefully inspected for the ureters which had already been identified bilaterally to be well away from the ovaries.  The infundibulopelvic ligament was serially desiccated and transected using the LigaSure.  Once the left ovary was freed it was placed down into the vagina with the tube and uterus.
Attention was then turned to the right where attempts at freeing up the bowel to ovarian adhesions were made.  The adhesions were noted to be so dense that any further attempts at adhesiolysis to free up the ovary would cause significant bowel trauma and potentially lead to colectomy, a partial colectomy, or bowel resection.  Given that the right ovary was noted to be completely normal and the removal was simply elective based on patient's desires, decision was made to leave the right ovary rather than open her abdomen to remove the right ovary.
At this time, attention was then turned to the vagina and using the Autosuture the vagina was closed in a running fashion.  Suture was noted to be slightly loose on the left corner.  Hemostasis however was obtained.  The abdomen was cleared of all clot, debris and blood, and hemostasis was assured.  The ports were removed under direct visualization.  The right sided port was fascial was then closed with a figure-of-eight suture of 1-0 Vicryl.  The skin was then reapproximated with subcutaneous stitches and Dermabond was applied.
Attention was then turned to the vagina where the uterus, tube and ovary were removed from the vagina in whole.  The vagina was noted to be hemostatic, however sutures did appear loose in the left corner compared to the preferred reapproximation.  Given this finding 0 Vicryl was utilized to close the left corner more tightly.  Most excellent closure was appreciated in the vagina.  The speculum was removed.  Excellent hemostasis was noted.
Sponge, lap, and needle counts were correct x 2.  The patient was taken the recovery room in stable condition.

COMPLICATIONS:  None.

PATHOLOGY:
1. Cervix.
2. Uterus.
3. Left tube and left ovary.


Thanks in advance for your help!

Michelle


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## Jr142325 (Mar 20, 2009)

I think 58571 with modifier 22  for the extra work involved with the adhesions would be appropriate.  Any one have other thoughts??


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## Anastasia (Mar 23, 2009)

I would agree but would want to know size of uterus from path report. With a 10-week size uterus, could be greater than 250 grams.


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