# Help coding - Could someone help me out with the op note below



## vmounce

Could someone help me out with the op note below?  I thought CPT 58662 would be correct.  I appreciate any reply.              

Vickie Mounce, CPC

PREOPERATIVE DIAGNOSIS:  
Unwanted fertility                                                                           

POSTOPERATIVE DIAGNOSES: 

Unwanted fertility. 
Extensive pelvic adhesions. 
Bilateral large noncommunicating hydrosalpinx. 


PROCEDURE:  Laparoscopy with bilateral tubal ligation.    

 ANESTHESIA:   General.

 INDICATION:  This is a 41-year-old patient who had a tubal ligation, a tubal reversal, and a total of three deliveries.  She had a Mirena in place that had been removed on her last visit.  She opted for repeat tubal ligation.  Options were explained to her and she elected to proceed with the procedure.  The procedure and risks were explained to her and all of her questions were answered.  The possibility of trauma, bleeding, infection, the need for a second surgery, the need for laparotomy, failure rate, and difficulty of  reversal, etc., were all addressed with her.  


OPERATIVE PROCEDURE:  After general anesthesia with endotracheal intubation, the patient was placed in gynecological position in Allen stirrups.  Betadine prep was done.  Bladder catheterization and sterile drapes were placed as usual.  The uterus was examined and it is anteverted.  There is no adnexal mass.  There is no string as the IUD had been removed.  A weighted speculum is inserted.  The uterine manipulator is put in place and the anterior lip of the cervix was grasped with a single-toothed tenaculum.  I infiltrated the infraumbilical area with a few ml of Marcaine 0.5% with Epinephrine.  A small transverse incision was made through which I inserted a Veress needle, the position of which was checked by instilling a few mL of saline with no return.  The drops of saline flowed in easily.  I created a pneumoperitoneum with 2.5 liters of CO2 under a pressure of less than 15 mmHg. 


The Veress needle was withdrawn and a 5 mm trocar was inserted along with the laparoscope, which enabled me to see that I was well inside the abdominal cavity.  There are extensive adhesions so a suprapubic trocar was then inserted just lateral to midline on the right.  This was inserted under direct vision after local anesthesia and skin incision with the cold knife.  A 5 mm trocar was also inserted lateral to the left epigastric vessels in paraumbilical fashion again under direct visualization.  Meticulous dissection was carried out.  The pelvis is completely obliterated by adhesions.  Attention was done to the adhesions of the rectosigmoid and bowel that are in the midline.  I was finally able to visualize the pelvis on both sides.  There are bilateral noncommunicating hydrosalpinx about 5-6 cm on each side.  I was able to visualize the ovaries underneath.  The adhesions are mobilized and hemostasis was achieved with the bipolar forceps at a power of 30 watts.  I was able to cauterize the proximal part of the tube on both sides with the bipolar forceps at a power of 30 watts.  It was cauterized at multiple areas always being sure that I was away from the ureters, bowel, or any other structures.  During dissection, the hydrosalpinx were opened and fluid came out which was suctioned.  With the distal hydrosalpinx being opened and with proximal cauterization I was very pleased with the results.  Hemostasis was achieved perfectly.  It was verified also while decreasing the abdominal pressure to less than 10.  Hemostasis was perfect.  Irrigation of the pelvic cavity was done with saline.  All the fluid was suctioned.  I am pleased with the results.  


The patient will be seen tomorrow for close surveillance and she will be kept longer in the recovery room for monitoring.


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## SS62

Hi 
58662 is for excision of lesions of ovary, pelvic viscera, or peritoneal surface.  It looks like 58670 may be more the way to go.  
Lysis is inclusive.


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## codedog

Simplify Your Tubal Ligation Codes By Focusing on 3 Details




Ligations with cesarean deliveries may be an uphill battle – here’s why

You can sort through your tubal ligation choices if you zero in on the ob-gyn’s technique (laparoscope or hysteroscope versus open procedure), transaction (device or fulguration) method, and delivery involvement. 

When a patient no longer wishes to conceive children and requests a tubal ligation, you’ve got multiple coding options: a set of codes for procedures performed vaginally or via an open approach, a set of codes for laparoscopic procedures, and a code for Essure tubal ligations. 

Note: You’ll always report a tubal ligation with V25.2 (Sterilization), no matter which type of tubal ligation the ob-gyn performs or the reason the patient (or patient’s legal guardian) requested the tubal, says Melanie Witt, RN, CPC-OGS, MA, an independent ob-gyn coding consultant in Guadalupita, N.M. 

Did MD Use a Laparoscope? Look to 2 Codes

If your ob-gyn uses a laparoscope, you will report either 58670 (Laparoscopy, surgical; with fulguration of oviducts [with or without transection]) for a diathermied tube and 58671 (... with occlusion of oviducts by device [e.g., band, clip, or Falope ring]) if a device occludes the tube. 

Look out: If an ob-gyn performs a “minilaparoscopic tubal,” you will look to these two codes as well, Witt points out – but look at the technique to determine which code to use. These two codes differ based on technique regardless of whether the ob-gyn performs the ligation on its own or following a delivery. 

Focus on 4 Options for Open/Vag Procedures

If your ob-gyn does not use a laparoscope and performs an open or vaginal procedure, you will report one of these four options: 

58600 – Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral 
58605 – Ligation or transaction of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure) 
8611 – Ligation or transaction of fallopian tube(s) when done at the time of cesarean delivery or intraabdominal surgery (not a separate procedure) (list separately in addition to code for primary procedure) 
58615 – Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring) vaginal or suprapubic approach. 

Keep in mind: Sometimes, physicians refer to a tubal procedure as a “Pomeroy tubal,” Witt says. This technique involves tying a section of the tube, then removing it. Your ob-gyn can perform this via laparoscope (58670) or via an open procedure (58600, 58605, 58611). You will not report a device code for this technique. 

Do This When Ligation Follows Vaginal Delivery 

You can report the tubal ligations following a vaginal delivery (59400, 59409-59410). If the tubal ligation occurs immediately after the delivery (during the same operative session), use 58605 with modifier 59 (Distinct procedural service) appended. 

Remember: You should use modifier 59 to identify procedures that are distinctly separate from any other procedure the physician provides on the same date, says Suzan Berman-Hvizdash, CPC, CPC-EM, CPC-ED, coding and compliance manager, UPMC-UPP Department of Surgery. In this case, modifier 59 tells the payer the tubal ligation was a distinct service from the delivery even though they occurred during the same session. 

Good news: Because the tubal ligation requires a separate incision and is essentially unrelated to the vaginal delivery, carriers that pay for the ligation under other circumstances will generally not take issue with reimbursement using this coding sequence. 

Beware: Some carriers may pay less for tubal ligation when reported with modifier 59. Some policies reason that the prep work has already been done for the patient prior to delivery and that there is no need to pay twice for the same work, Witt warns. 

Keep in mind: If the tubal ligation occurs a day or more after the delivery (during the same hospital stay), use 58605 with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period). You should receive full reimbursement for the procedure. 

Cesarean Delivery With Ligation May Be a Battle 

Cesarean delivery frequently offers the ob-gyn the chance to perform tubal ligation immediately after the delivery, sparing the patient an additional surgical session. You’ll report 58611 in this case. 

Red flag: Billing for tubal ligation at the time of cesarean is almost always a problem with payers because they count the cesarean incision as the incision for the ligation, Witt says. To these insurers, the ligation at the same session does not represent significant effort for the ob-gyn. 

Although the American College of Obstetricians and Gynecologists (ACOG) specifically leaves tubal ligation off the list of bundled procedures in its policy on cesarean deliveries and global ob care with cesarean, some carriers will pay little or nothing extra for the procedure, Witt says. 

Money saver: Tubal ligation performed at the time of cesarean delivery can prove a significant source of revenue, so practices should negotiate contract renewal to see that the procedure is reimbursed separately from the global package or cesarean delivery codes. “Also, you should point out to the payer that 58611 is an add-on procedure that does not take a modifier,” Witt says. The Resource-Based Relative Value Scale (RBRVS) valued this code based solely on the intraoperative work. 

Don’t Overlook Essure Procedure 

Your ob-gyn can also perform an Essure procedure, which involves implants into the fallopian tubes. For this procedure, you’ll use 58565 (Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants). 

Note: If the ob-gyn placed the device in only one tube (for instance, if the other tube was already blocked), you should add modifier 52 (Reduced services) to this code.


 hope this helps  trent


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## vmounce

I appreciate the replies and information that was sent.

Vickie


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## rose2014

*Hospital fup visit after 58662*

So Dr. performed procedure 58662.

Day 1
58662
99223-AI, 57,
Day 2 
99232.

Ins paid 58662,99223 but 99232 got bundled ,my question is will fup be bundled with 90 day GP.Any way it can be unbundled.

Thanks for input


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## kbarrf

*Laparocopic removal of Flope-rings*

I have a question on how to code for removal of the Falope_ring due to pain. How would you code using the laparoscope?


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