Hi list,
Based on below, would you only code 57265? Still trying to tackle some of the OB/Gyn surgeries.
Any help is greatly appreciated!
PROCEDURE:
Cystocele repair, rectocele repair, enterocele repair, vaginal
cuff suspension and cystoscopy.
ANESTHESIA:
General.
DESCRIPTION OF PROCEDURE:
After induction of satisfactory general anesthesia, the patient
was prepped and draped in usual sterile manner for vaginal
surgery. The bladder was drained with return of clear urine.
She was noted to have the vaginal apex prolapse to the hymen
along with the transverse portion of the anterior compartment and
the upper portion of the posterior compartment. The perineal
body was hypermobile. She also was noted to have a midline
rectocele.
Marking sutures were placed at 3 and 9 o'clock. A vertical
incision was made in the anterior compartment from the proximal
portion of the anterior compartment across the cuff into the
upper portion of the posterior compartment. The vaginal
epithelium was reflected away from the underlying connective
tissue. The enterocele sac was entered by sharp dissection. The
remnants of uterosacral ligament were identified on each side.
The bowel was packed out of the operative field. The suture 0
Maxon followed by 2 sutures of 2-0 Tycron were placed posterior
and medial to the ischial spines on both sides. The suspensory
sutures were placed in the transverse portion of the rectovaginal
septum, and pubocervical fascia. Lap and sponge count were
correct x2. The suspensory sutures were tied giving excellent
support to the apex of the vagina and correction of the support
defects. The bladder was drained with return of clear urine.
Cystoscopy was performed using a 70-degree cystoscope and 100 mL
of 50% dextrose. Urine was noted to come promptly from both
ureteral orifices. These there was no evidence of injury to the
bladder or urethra. The bladder was drained. The suspensory
sutures were trimmed. The epithelial incision was closed with
continuous Vicryl suture. There was excellent support for the
apex of the vagina and correction of the apical defects.
A digital rectal exam was performed. She was noted to have a
midline rectocele and a vertical incision was performed inside
the vaginal canal just inside the genital hiatus. The vaginal
epithelium was reflected away from the underlying rectovaginal
septum. The septum was approximated using interrupted 2-0 Vicryl
sutures. The skin was closed with subcuticular 3-0 Vicryl
suture.
A small tag of tissue at 5 o'clock at the hymen was excised and
the skin incision closed with 3-0 Vicryl.
Lap and sponge counts were correct. Hemostasis was good. The
patient received 800 mL of normal saline intravenously. Blood
loss was approximately 100 mL. She was given 30 mg of Toradol
intravenously. A vaginal pack covering with clindamycin was
placed in the vaginal canal. The catheter was left draining
clear urine. The patient was returned to the recovery room
stable.
Based on below, would you only code 57265? Still trying to tackle some of the OB/Gyn surgeries.
Any help is greatly appreciated!
PROCEDURE:
Cystocele repair, rectocele repair, enterocele repair, vaginal
cuff suspension and cystoscopy.
ANESTHESIA:
General.
DESCRIPTION OF PROCEDURE:
After induction of satisfactory general anesthesia, the patient
was prepped and draped in usual sterile manner for vaginal
surgery. The bladder was drained with return of clear urine.
She was noted to have the vaginal apex prolapse to the hymen
along with the transverse portion of the anterior compartment and
the upper portion of the posterior compartment. The perineal
body was hypermobile. She also was noted to have a midline
rectocele.
Marking sutures were placed at 3 and 9 o'clock. A vertical
incision was made in the anterior compartment from the proximal
portion of the anterior compartment across the cuff into the
upper portion of the posterior compartment. The vaginal
epithelium was reflected away from the underlying connective
tissue. The enterocele sac was entered by sharp dissection. The
remnants of uterosacral ligament were identified on each side.
The bowel was packed out of the operative field. The suture 0
Maxon followed by 2 sutures of 2-0 Tycron were placed posterior
and medial to the ischial spines on both sides. The suspensory
sutures were placed in the transverse portion of the rectovaginal
septum, and pubocervical fascia. Lap and sponge count were
correct x2. The suspensory sutures were tied giving excellent
support to the apex of the vagina and correction of the support
defects. The bladder was drained with return of clear urine.
Cystoscopy was performed using a 70-degree cystoscope and 100 mL
of 50% dextrose. Urine was noted to come promptly from both
ureteral orifices. These there was no evidence of injury to the
bladder or urethra. The bladder was drained. The suspensory
sutures were trimmed. The epithelial incision was closed with
continuous Vicryl suture. There was excellent support for the
apex of the vagina and correction of the apical defects.
A digital rectal exam was performed. She was noted to have a
midline rectocele and a vertical incision was performed inside
the vaginal canal just inside the genital hiatus. The vaginal
epithelium was reflected away from the underlying rectovaginal
septum. The septum was approximated using interrupted 2-0 Vicryl
sutures. The skin was closed with subcuticular 3-0 Vicryl
suture.
A small tag of tissue at 5 o'clock at the hymen was excised and
the skin incision closed with 3-0 Vicryl.
Lap and sponge counts were correct. Hemostasis was good. The
patient received 800 mL of normal saline intravenously. Blood
loss was approximately 100 mL. She was given 30 mg of Toradol
intravenously. A vaginal pack covering with clindamycin was
placed in the vaginal canal. The catheter was left draining
clear urine. The patient was returned to the recovery room
stable.