# Help coding - I'm not sure the coding for the following op not



## snjberry (Nov 15, 2012)

I'm not sure the coding for the following op note.  Any help would be greatly appreciated

PREOPERATIVE DIAGNOSIS: Cervical dysplasia
POSTOPERATIVE DIAGNOSIS: Cervical dysplasia 

BRIEF SUMMARY:  is a 23-year-old Gravida 0, last menstrual period uncertain with dysplasiaof anterior and posterior cervical portio expanding on colposcopy into the os. Endocervical curettage at colposcopy was positive for CIN-I and the ectocervix T-zone at the os was positive for CIN I, II and possibly III. The patient presents today for the following procedure, a loop electrode excision procedure of the cervix with a second endocervical pass by a deep endocervical electrode.
ANESTHESIA: General with endotracheal intubation

SURGEON: Dr. 

FINDINGS: Under Lugol's staining the anterior and posterior cervical os show areas of Lugol's positive. There is no other Lugol's positive on the cervix or the vaginal cervical junction area. 

PROCEDURE: The patient was brought to the OR and placed on the table and general anesthetic was administered. The patient was placed in dorsal lithotomy position. With a sterile urethral prep the bladder was catheterized for a small amount of clear amber urine. After washing and using a clean technique with sterile gloves the surgeon places a large LEEP speculum in the vagina and exposes the entire cervix well. Lugol's staining is performed. The speculum is rotated 90 degrees to each side and the upper vagina and the cervix are observed. Findings as described above. Then using an 8 x 20 electrode for the outer cervix a single clean pass at 100 watts on blend is made. An ectocervical specimen well encompassing the Lugol's positive areas obtained and a stitch is placed at 12 o'clock. There is only a trace of bleeding from this first pass. A second pass with a 10 x 10 electrode is again made deep in the endocervix obtaining a clean sample that contains the endocervix penetrating a total of approximately 1 ¾ to 2cm into the cervical canal. There is moderate bleeding observed after this pass. Ball cautery is used and hemostasis is gradually achieved. The patient has been observed for a few minutes and there is just some slight point bleeding on the deep part of the LEEP and ball cautery is applied
carefully and it results in excellent hemostasis. The patient is again observed for a few minutes and hemostasis is perfect so we apply Lugol's solution to the surgical site and then remove the speculum and awaken the patient and discharge her to the Recovery Room. Pathology specimens are ectocervix and endocervix LEEP specimen and LEEP cone. Estimated blood loss 100cc. Complications are none.


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## kvangoor (Nov 15, 2012)

57522. Whenever you read the term "LEEP", its most likely this code.


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