# Vaginal Cuff Revision Release Ureterosacral ligament suture



## FLSJarrel (Dec 2, 2011)

Could someone point me in the correct direction for the following procedure.  I am new to OBGYN coding & this one has me stumped.  Thanks for any help.  Note:  I am billing for Doctor B.

PREOPERATIVE DIAGNOSES: 
1.   A 58-YEAR-OLD WHITE FEMALE 2 DAYS STATUS POST HIGH UTEROSACRAL LIGAMENT SUSPENSION. 
2.   RULE OUT RIGHT URETERAL INJURY. 

POSTOPERATIVE DIAGNOSIS:  KINKED RIGHT URETER WITH PATENT LUMEN AND NORMAL BLADDER, STATUS POST STENT PLACEMENT IN THE RIGHT URETER. 

OPERATION: 
1.   DIAGNOSTIC CYSTOSCOPY WITH RIGHT URETERAL STENT PLACEMENT DONE BY DR. A. 
2.   REVISION OF VAGINAL CUFF AND RELEASE OF RIGHT URETEROSACRAL LIGAMENT SUTURES, BOTH THE PDS AND ETHIBON SUTURE By Dr. B, DR. A ASSISTING. 

TECHNIQUE:  The patient was counseled about the potential for right ureteral injury and the need to proceed with diagnostic cystoscopy with possible stent placement and revision of the vaginal cuff with release of the right ureterosacral ligament sutures.  Consent was obtained, all questions answered, risks discussed. 

The patient was taken to the operating room and placed under general anesthesia in the dorsal lithotomy position in Allen stirrups.  The patient received 1 dose of gentamicin and clindamycin for prophylaxis and then the lower abdomen, perineum and vagina were scrubbed, and the patient was draped in the usual sterile fashion.  Procedure was started by Dr. A with a diagnostic cystoscopy done followed by insertion of right ureteral stent under fluoroscopic guidance.  Upon entry into the bladder, the bladder appeared to be normal.  Both ureteral orifices were identified and then a 5-French catheter was introduced into the right ureteral orifice and contrast dye was injected.  X-ray images showed patent lumen of the right ureter, however, there was sharp kinking in the distal pelvic portion of the ureter with a very sharp angle, which most likely is a result of the ureterosacral ligament sutures tension on the tissues around the right ureter.  A curved tip wire was able to be negotiated and passed through the angle and then the ureter assumed a straight position.  After that, a stent was placed by Dr. A and was left in the proper position in the right kidney and with the distal end curled inside the bladder.  After that, revision of the vaginal cuff was performed by Dr. B with assistance by Dr. A and using right angle retractors, the vaginal cuff was visualized and grasped with Allis at the right vaginal angle.  Of note, the vaginal cuff was suspended at the high level with a total length of the vagina around 10 cm.  This made this part a little bit challenging, however, the PDS suture was first identified and was cut loose and this allowed progression and removal of two more of the 2-0 Vicryl suture at the right side of the vaginal cuff. The Ethibon suture was then visualized and was held with a long needle holder and cut sharply under direct vision.  At that point, the vaginal cuff became open on the right side and all the tension was gone.  Then, the vaginal cuff was reapproximated using 4 figure-of-8 sutures with 2-0 Vicryl.  Good hemostasis was noted during the procedure.  The sutures were cut free and then cystoscopy was repeated by Dr. A.  There was evidence of peristalsis of the right ureter with the stent moving in place.  Indigo carmine was given.  There was little view of indigo carmine noticed at that time.  Dr. A elected to terminate the procedure at that point.  He was reassured with the results and the patient was extubated and transferred to the post-anesthesia care unit in stable condition.


----------



## ajs (Dec 2, 2011)

FLSJarrel said:


> Could someone point me in the correct direction for the following procedure.  I am new to OBGYN coding & this one has me stumped.  Thanks for any help.  Note:  I am billing for Doctor B.
> 
> PREOPERATIVE DIAGNOSES:
> 1.   A 58-YEAR-OLD WHITE FEMALE 2 DAYS STATUS POST HIGH UTEROSACRAL LIGAMENT SUSPENSION.
> ...



Unfortunately since there was not revision of a graft from the previous procedure, you are left with the unlisted code 58999.  The closest procedure code to what your doc did was 57295 so maybe you could use that with a modifier 52 to indicate it was less than what is described.  Either way you will probably have to send the op report and ask for a review of the claim.


----------



## FLSJarrel (Dec 5, 2011)

Thanks for your input.  I was figuring it would be an unlisted code, but was not sure if I had missed something.


----------

