Hi Ob coders,
needing some assistance here. First time seeing this and not too sure of myself on this one.
59812?? and what dx code would you assign?
tia
JNB,CCS,CPC
A/P - Blighted ovum
1. Recommend proceed with D&C Risks of the procedure were discussed with the patient most notably pain, infection, damage to internal organs - most notably uterine perforation, Asherman's syndrome, risk of anesthesia, risk of blood transfusion (Hep C / HIV), DVT / PE, and possibility for death. Despite these risks the patient desires to proceed and consents were signed and placed in the chart.
2. Rx's were given for postop pain management
3. RTC - 1 week - Blood type - O pos
OP NOTE:
Preop dx - 1. 1st trimester - Anembryonic gestation
Postop dx - same
Procedure - Dilation & suction curettage
Surgeon -
Anes - GETA
EBL - 400 mL
IVF - 1000 mL
U/O - 50 mL
Pathology - POC's
Findings - NEFG without lesions.
Procedure - The patient was taken to operating room # 8 in the main OR, and after GETA was obtained, the patient was prepped and draped in routine fashion and placed in the high hanging stirrups. A heavy weighted speculum was placed in the posterior vagina, and a right angle retractor was placed in the anterior vagina. The cervix was identified and the anterior lip was grasped with a single tooth tenaculum. The cervix was noted to be closed, therefore, it was dilated with Hank's dilators to a #14. A 7 cm curved curette was placed in the uterine cavity, and a suction curettage was performed. After two passes where no tissue was noted, the suction curette was removed and a sharp curette was used to remove any underlying tissue. The uterine lining was noted to feel "gritty". The suction curette was then used for two more passes to remove any underlying blood. A 0.2 mg IM injection of Methergine was given.
The vagina was then irrigated and the irrigant removed. The area was noted to be hemostatic, and then all instruments were removed form the vagina. All sponge, lap, & needle counts were correct times two at the end of the procedure.
PATH:
CASE: SS-15-41883
PATIENT:
BRIEF CLINICAL HISTORY
Products of conception.
GROSS:
Specimen labeled products of conception is a 7.0 x 5.5 x 2.5 cm
aggregate of spongy, papillary and membranous red-pink fragments and
blood clot. Representatively submitted in 1A-1C.
JP/sc
MICROSCOPIC DIAGNOSIS:
Products of conception, tissue submitted: Chorionic villi, decidua,
membranes and
decidualized inactive endometrium; consistent with products of
conception.
needing some assistance here. First time seeing this and not too sure of myself on this one.
59812?? and what dx code would you assign?
tia
JNB,CCS,CPC
A/P - Blighted ovum
1. Recommend proceed with D&C Risks of the procedure were discussed with the patient most notably pain, infection, damage to internal organs - most notably uterine perforation, Asherman's syndrome, risk of anesthesia, risk of blood transfusion (Hep C / HIV), DVT / PE, and possibility for death. Despite these risks the patient desires to proceed and consents were signed and placed in the chart.
2. Rx's were given for postop pain management
3. RTC - 1 week - Blood type - O pos
OP NOTE:
Preop dx - 1. 1st trimester - Anembryonic gestation
Postop dx - same
Procedure - Dilation & suction curettage
Surgeon -
Anes - GETA
EBL - 400 mL
IVF - 1000 mL
U/O - 50 mL
Pathology - POC's
Findings - NEFG without lesions.
Procedure - The patient was taken to operating room # 8 in the main OR, and after GETA was obtained, the patient was prepped and draped in routine fashion and placed in the high hanging stirrups. A heavy weighted speculum was placed in the posterior vagina, and a right angle retractor was placed in the anterior vagina. The cervix was identified and the anterior lip was grasped with a single tooth tenaculum. The cervix was noted to be closed, therefore, it was dilated with Hank's dilators to a #14. A 7 cm curved curette was placed in the uterine cavity, and a suction curettage was performed. After two passes where no tissue was noted, the suction curette was removed and a sharp curette was used to remove any underlying tissue. The uterine lining was noted to feel "gritty". The suction curette was then used for two more passes to remove any underlying blood. A 0.2 mg IM injection of Methergine was given.
The vagina was then irrigated and the irrigant removed. The area was noted to be hemostatic, and then all instruments were removed form the vagina. All sponge, lap, & needle counts were correct times two at the end of the procedure.
PATH:
CASE: SS-15-41883
PATIENT:
BRIEF CLINICAL HISTORY
Products of conception.
GROSS:
Specimen labeled products of conception is a 7.0 x 5.5 x 2.5 cm
aggregate of spongy, papillary and membranous red-pink fragments and
blood clot. Representatively submitted in 1A-1C.
JP/sc
MICROSCOPIC DIAGNOSIS:
Products of conception, tissue submitted: Chorionic villi, decidua,
membranes and
decidualized inactive endometrium; consistent with products of
conception.
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