# Multiple surgical procedures done, need 2nd opinion on coding this!!



## mraymond74 (May 11, 2009)

Calling all who can help with this one.  I have a doctor that likes to due multiple surgical procedures at 1 time. And he has got me on this one!!
Here is what I have.
I have attached a copy of the note below.

For Procedure 1. 58558 
procedure 2.  (this is were I get confused) for Laparoscopy w/ lysis of adhesions. I have 58660 & Laparoscopy of r. salpingectomy & lft ovarian cystecomy. I have 58661. CCI edits state I cannot bill both.  The doctor states he spent an hour with the lysis of adhesion. 
procedure 3. 58350

Anyone have any advise??? 


OPERATIVE REPORT

DATE OF OPERATION:   05/08/2009

PREOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Hydrosalpinx.
3. Dysmenorrhea.
4. Infertility.

POSTOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. A 4 cm left ovarian cyst and 8 cm right hydrosalpinx.
3. Extensive pelvic adhesions.
4. Periappendiceal adhesions and inflammation.
5. Possible endometrial polyp and intrauterine synechiae.

PROCEDURE:
1. Hysteroscopy, dilatation and curettage, lysis of adhesions, polypectomy.
2. Laparoscopy with extensive lysis of adhesions, right salpingectomy, left ovarian cystectomy.
3. Chromopertubation.
4. Appendectomy per Dr. Podnos.

ANESTHESIA:  General endotracheal and local.

FINDINGS:  As described above.

BLOOD LOSS:  50 ml.

URINE OUTPUT:  275 ml.

FLUIDS:  2900 ml.

DRAINS:  None.

COMPLICATIONS:  None.

SPECIMENS:
1. Endometrial curettings and possible polyp.
2. Right fallopian tube.
3. Left ovarian cyst wall.
4. Appendix.

DISPOSITION:  The patient to recovery room in stable condition.

HISTORY:  Preoperatively, Ms. H was seen as an outpatient for general gynecologic care.  She had a known history of a large hydrosalpinx and pelvic pain.  The pain had been worsening over recent months.  At her recent presentation, she desired surgical intervention for the ongoing pain.  In addition to the chronic pelvic pain, she had dysmenorrhea and irregular bleeding.  Ultrasound showed endometrial thickening, and a possible polyp.  Planned surgical procedure included removal of the damaged fallopian tube with possible removal of both fallopian tubes,  removal of ovarian cysts, if present, laparoscopy.  Lysis of adhesions was discussed at length. Risks and complication with laparoscopy given the patient's complicated surgical history were reviewed at length preoperatively.  In addition, hysteroscopy was planned for evaluation of the endometrium with possible polypectomy.  Finally, chromopertubation was discussed to evaluate the remaining fallopian tube.  The patient had a long-standing history of infertility, and desired the possibility for future assistive reproductive technology interventions if possible. Primary indication this procedure is the patient's chronic and worsening pelvic pain.
The risks of hysteroscopy reviewed included, but were not limited to, bleeding, infection, uterine perforation and possible damage to surrounding structures.  Risks of laparoscopy reviewed included, but were not limited to, bleeding, infection, damage to internal organs such as bowel, bladder, ureters and major blood vessels.  Given the patient's complicated surgical history, the possible need for laparotomy was also discussed.  She voiced her understanding of the procedure and hospital consent was obtained.

DETAILS OF OPERATIVE TECHNIQUE:  Ms. H was taken to the operating room where general endotracheal anesthesia was found to be adequate.  She was prepped and draped in sterile fashion in the dorsal lithotomy position.  Bladder was emptied via Foley catheterization.  Exam under anesthesia revealed a mobile uterus.  No uterine masses were appreciated.  The left adnexa was somewhat full.   Rectovaginal exam revealed a fullness in the cul-de-sac.  Gloves were changed, and a speculum was placed in the vagina.  The cervix was grasped with a single-toothed tenaculum, and the cervix was dilated to allow for the diagnostic hysteroscope to be placed within the uterine cavity.  The cervical canal appeared within normal limits.  There was an elongated polypoid structure emanating from the left posterior aspect of the uterine cavity.  In addition, areas of uterine synechiae were noted, especially in the cornual regions.  The polyp forceps were used to remove the elongated structure.  Endometrial curettings were then taken until the uterus was felt to be clean in all directions.  The hysteroscope was replaced within the uterine cavity.  The synechiae had been broken down with a curet.  No further polypoid materials were noted.  The right fallopian tubal ostium appeared somewhat closed and pinpoint in appearance.  The left appeared within normal limits.  The instruments were removed from the uterus.  The HUMI uterine manipulator was then placed.  The single-toothed tenaculum was removed.  The speculum was removed from the vagina.  Gloves were changed.  Attention was turned to the laparoscopic field.
A left upper quadrant entry was chosen secondary to the patient's complicated surgical history.  A 5 mm infraclavicular incision was made in the midaxillary line.  The Veress needle  was entered into the abdominal cavity without difficulty.  Normal saline drip test and normal CO2 filling pressures were noted.  Pneumoperitoneum was created without difficulty.  The Veress needle was removed, and the 5 mm Optiview trocar was introduced into the abdominal cavity under direct and laparoscopic visualization without complications.
The patient was placed in Trendelenburg position, and areas for safe entry with other ports were identified with the laparoscope.  There were no significant umbilical adhesions.  Umbilical incision was made, and the trocar was entered without complications.  The camera was then placed in the umbilical area.  A right lower quadrant port was then placed. The laparoscopic scissors were used to take down omental adhesions from the anterior abdominal wall.  The uterus was then elevated, and areas of adhesions were noted.  A left lower quadrant port was placed under direct laparoscopic visualization.  Using a combination of bipolar cautery and the laparoscopic scissors, adhesions were taken down to allow for mobility of the right fallopian tube.  The right fallopian tube was densely adherent in the cul-de-sac and to the right pelvic sidewall.  A 4 cm left ovarian cyst was noted.  Dense bands of adhesions from small bowel to the posterior aspect of the uterus were noted x 2.  General surgery was called for evaluation of this dense adhesion and the appendix.  The appendix was noted to be elongated, with what appeared to periappendiceal adhesions and inflammation.  The appendix tip dove into the area of the right fallopian tube and cul-de-sac.  In sequential fashion, after adhesiolysis was undertaken, the right fallopian tube was mobilized.  The Kleppinger device was used to coagulate the tube proximally just until the cornual region of the uterus.  The mesosalpinx was dissected with the laparoscopic scissors.  With gentle traction toward the midline, it was possible to identify a plane of dissection.  With continued dissection, the tube was mobilized and completely detached.  The right ovary appeared to be within normal limits.  This area of  dissection was irrigated and cleared of clot and debris.  No ongoing bleeding was noted.  The ovarian cyst was then entered with the laparoscopic scissors.  The cyst wall was peeled out with the atraumatic grasper.  The cyst bed was irrigated and noted to be hemostatic.  The left fallopian tube appeared somewhat tortuous just prior to the distal fimbriated end.  It also appeared to be slightly dilated.
Periadnexal adhesions were taken down.  The fimbria did appear to be open, however.
The cul-de-sac was also noted to have adhesions from small bowel to the posterior aspect of the uterus.  These were taken down sharply with cautery.  No significant bleeding was encountered.  Good planes of dissection were noted between the bowel and the uterus.  At this time, Dr. P arrived in the operating room, and he proceeded to take down the dense band of adhesions from the small bowel to the posterior fundal aspect of the uterus.  This was done without complication.  He also agreed with the need to remove the appendix, given its distorted appearance and the adhesions in the right pelvic sidewall. This was done without complication, as well.  Please see his operative note for full details of this portion of the procedure.
The pelvis was copiously irrigated and cleared of any clots and debris.  The areas of dissection were reinspected and noted to be hemostatic.  At this time, a dilute solution of methylene blue was entered into the HUMI uterine manipulator, and, after initial slight loculation at the slightly dilated portion of the distal fallopian tube, the dye did come out through the fimbriated end.  Given the ability of the dye to pass through the tube, a large amount of the diluted solution of methylene blue was pushed through the fallopian tube in hopes of breaking up any internal tubal obstruction.  Once again, the pelvis was irrigated and cleared of the methylene blue solution.  Areas of dissection were reinspected under normal low abdominal filling pressures.  No bleeding was noted.  Instruments were then removed from the abdomen.  Pneumoperitoneum had been released.  The umbilical incision was closed with a deep suture of 0 Vicryl for fascial closure.  Skin incisions were closed with 4-0 Vicryl.  Marcaine was instilled into the incisions.  The Foley catheter and HUMI manipulator were removed.
Ms. H tolerated the procedure well.  All sponge, lap, needle and instrument counts were correct x 2.  She was transferred awake and in stable condition to the recovery room.


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## pahtrisha (May 12, 2009)

I'll take a crack at this for you, but there are probably multiple ways that this could be coded. Also, you should check to see what payer-specific guidelines may exist with regard to multiple procedures through the hystero- and laparoscopes.

Keep in mind, that 58660 is ALWAYS included in 58661 and 58662. The op note states that surg had to lyse some adhesions in order to reach the operative site on the tubes/ovaries. Most payers will not pay extra for this.  If lysis of *dense anatomy-distorting *adhesions are required and the dictation clearly states the amount of extra work that was required (usually in extra time spent and/or detailed descriptions), then you could ask for extra money and add modifer 22.  This dictation doesn't clearly document the amount of extra work involved, nor does it describe the adhesions as dense or state the extent of the extra work required. The -22 seems kind of iffy to me on this one.  Lysis IS separately reportable if it is at a separate site from the primary procedure, but in this case it looks like your doc didn't attemtpt the other adhesions but called in a general surgeon.  
CPT has designated 58661 as UNILATERAL (though Medicare has NOT), so, in theory, you could add -50. Two different sides - rt ov and lt tube.  
As for the hysteroscopy you could report 58559 and 58558-51. 59559 for the uterine synechiae has higher RVS than 58558 and so would be listed first.
Chromopertubation, when done to check the surgeons work is not separately reportable.
Hope this helps


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