# need help with two failed procedures



## ggparker14 (Feb 16, 2011)

Need help coding CPT and diagnosis.  Thank you.

Dilatation of the cervical canal done followed with hysteroscopy. Both ostia were seen (we did have some difficulty with _____ through that scope, but at the end both ostia were seen), and attempt to push in the Essure through the right tube, half of the Essure went into the tube and then we could not push it any further suggestive of either tubal occlusion or spasm. We tried for a good period of time from different postions and movement of the uterus and the scope but this failed at the end. The procedure was aborted and we decided to proceed with a laparoscopic bilateral tubal cauterization. Uterine manipulator was then put in. Anesthesia then decided to intubate the patient and the nurse anesthetist and Dr. tried to do that. They were not successful so the procedure was aborted for safety procedure. The uterine manipulator was removed and patient was taken to recovery.


----------



## preserene (Feb 16, 2011)

CPT- 58565 -52 -53, 00851-53

ICD- 9CM-- 629.8, V25.2/and or V25.8, V64.3,

Hope this could help to some extent


----------



## mitchellde (Feb 17, 2011)

preserene said:


> CPT- 58565 -52 -53, 00851-53
> 
> ICD- 9CM-- 629.8, V25.2/and or V25.8, V64.3,
> 
> Hope this could help to some extent



You cannot use both a 52 and a 53 on the same line item, you should report just a hysteroscopy since that is what was done.  Then because you have a procedure accomplished you do not report a discontinued.  Also only the anesthesiologist will report his codes.  As far as the dx codes go, I see nothing in this documentation that gives a dx at all, we cannot give the dx of a disorder of the female genital organs since it is not stated by the physician.  If you have more documentation to give a dx that would be great.  We assume the Essure is for contraception but we cannot code from what we assume.


----------



## ggparker14 (Feb 17, 2011)

The patient desired sterility and this was listed on the op report under postoperative diagnosis.  Would I also need to show the V64.x for the failed procedure?

Thank you for your help.


----------



## mitchellde (Feb 17, 2011)

No you would not use that since you are not reporting the failed.  When you have completed and failed you should only report the procedure that was accomplished.


----------



## preserene (Feb 17, 2011)

rhblevins61@yahoo.com said:


> Need help coding CPT and diagnosis.  Thank you.
> 
> Dilatation of the cervical canal done followed with hysteroscopy. Both ostia were seen (we did have some difficulty with _____ through that scope, but at the end both ostia were seen), and attempt to push in the Essure through the right tube, half of the Essure went into the tube and then we could not push it any further *suggestive of either tubal occlusion or spasm. We tried for a good period of time from different postions and movement of the uterus and the scope but this failed at the end. The procedure was aborted and we decided to proceed with a laparoscopic bilateral tubal cauterization. *Uterine manipulator was then put in. Anesthesia then decided to intubate the patient and the nurse anesthetist and Dr. tried to do that. They were not successful so the procedure was aborted for safety procedure. The uterine manipulator was removed and patient was taken to recovery.



What I infer from the OP notes is :1) the Essure was aborted/ discontinued because of block or spasm already there on its way.
2) " decided to proceed with lapr. cauterization" but due to anesthesia failure , seems to be not carried out. What it mean by saying" for safety procedure"- is not clear to me.
What was the procedure then under taken to complete?!
Uterine manipulators are used for lifting or tilting the uterus to get a convenient positioning of the tubes for lapraroscopic better visualization.(sometimes also used for minilap or interval sterilization open approach)
There is no sign of completion of the "intended" occlusion or tubal sterilization (cautery/clip) procedure.
Mitchellde, could you please give the whole lot of coding assignment, for a better understanding of this scenario?
Thank you.


----------

