Jenetteis
Networker
I am trying to decide on whether or not to bill this Operative Report as 58563, 52 instead of 58558. I feel there is enough documentation to support 58563, 52. Any advice is greatly appreciated. Thank you
PREOPERATIVE DIAGNOSIS: Abnormal bleeding.
POSTOPERATIVE DIAGNOSIS:
1. Abnormal bleeding.
2. Stenotic cervix.
3. Sterile pyometra.
PROCEDURE PERFORMED:
1. Hysteroscopy.
2. Dilation and curettage.
DETAILS OF PROCEDURE:
Patient was taken to the operating room where satisfactory anesthesia was induced. She was placed in lithotomy position, prepped and draped in the usual manner. Exam under anesthesia revealed a normal-sized uterus with benign adnexa. The cervix was visualized with a speculum and grasped with a tenaculum. The direction of the cervical canal was initially attempted to be confirmed with a sound, but you could not pass a sound through the stenotic cervical opening. We then used a very small dilator and proceeded to larger dilators. When we first got our dilators through the cervix, we got about 10 mL of purulent-looking fluid coming out, which had the appearance of sterile abscess-type fluid. Once we got the cervix dilated sufficiently, we could pass the scope into the endometrial cavity. Evaluation of the endometrial cavity and of the endocervical canal showed a small polyp on the posterior uterine wall, but an otherwise generally unremarkable appearance, save for the fact that the patient had a narrow lower uterine segment. Endocervical curettings were obtained, endometrial curettings were obtained, and then the NovaSure device passed in the endometrial cavity. The problem was, due to the narrow lower uterine segment, no matter how we manipulated the device, trying multiple different depths and approaches into the uterus, we could not get the device to open any wider than 1.75 to 2.25 cm, which was in the red zone for the performance of the procedure; thus, the ablation could not be performed. An extensive amount of time was spent manipulating the device to see if there was any way we could get it open enough to perform the ablation, but we never got within 0.5 cm of the minimum opening felt safe. Therefore, at that point, the attempt to do the ablation was abandoned. Repeat hysteroscopy again showed no significant abnormalities, save as noted above. The tenaculum removed. The cervix inspected for adequate hemostasis, which was noted to be good. The speculum was removed, and this procedure was terminated. Sponge and lap counts were correct.
ESTIMATED BLOOD LOSS:
Less than 10 mL.
SPECIMENS REMOVED:
Sent to Pathology: Endometrial and endocervical curettings.
DISPOSITION:
Patient discharged to recovery room in stable condition.
PREOPERATIVE DIAGNOSIS: Abnormal bleeding.
POSTOPERATIVE DIAGNOSIS:
1. Abnormal bleeding.
2. Stenotic cervix.
3. Sterile pyometra.
PROCEDURE PERFORMED:
1. Hysteroscopy.
2. Dilation and curettage.
DETAILS OF PROCEDURE:
Patient was taken to the operating room where satisfactory anesthesia was induced. She was placed in lithotomy position, prepped and draped in the usual manner. Exam under anesthesia revealed a normal-sized uterus with benign adnexa. The cervix was visualized with a speculum and grasped with a tenaculum. The direction of the cervical canal was initially attempted to be confirmed with a sound, but you could not pass a sound through the stenotic cervical opening. We then used a very small dilator and proceeded to larger dilators. When we first got our dilators through the cervix, we got about 10 mL of purulent-looking fluid coming out, which had the appearance of sterile abscess-type fluid. Once we got the cervix dilated sufficiently, we could pass the scope into the endometrial cavity. Evaluation of the endometrial cavity and of the endocervical canal showed a small polyp on the posterior uterine wall, but an otherwise generally unremarkable appearance, save for the fact that the patient had a narrow lower uterine segment. Endocervical curettings were obtained, endometrial curettings were obtained, and then the NovaSure device passed in the endometrial cavity. The problem was, due to the narrow lower uterine segment, no matter how we manipulated the device, trying multiple different depths and approaches into the uterus, we could not get the device to open any wider than 1.75 to 2.25 cm, which was in the red zone for the performance of the procedure; thus, the ablation could not be performed. An extensive amount of time was spent manipulating the device to see if there was any way we could get it open enough to perform the ablation, but we never got within 0.5 cm of the minimum opening felt safe. Therefore, at that point, the attempt to do the ablation was abandoned. Repeat hysteroscopy again showed no significant abnormalities, save as noted above. The tenaculum removed. The cervix inspected for adequate hemostasis, which was noted to be good. The speculum was removed, and this procedure was terminated. Sponge and lap counts were correct.
ESTIMATED BLOOD LOSS:
Less than 10 mL.
SPECIMENS REMOVED:
Sent to Pathology: Endometrial and endocervical curettings.
DISPOSITION:
Patient discharged to recovery room in stable condition.