AileenN
New
Hello I just need help coding my Abdominal Hysterectomy
I code 58180 but I feel something is missing.
Here is the scenario
OPEN ABDOMINAL ENTRY:
A midline abdominal incision was made 2 cm above the symphysis pubis .
Gross inspection of the pelvic reviewed a dense adhesions, obliterated anterior cul-de-sac, with uterus densely adherent to the anterior abdominal wall and bladder. Careful dissection of the uterus was completed via assistance of blunt dissection, mayo scissors and cautery.
The left and right round ligaments were identified and suture ligated with 0 polysorb suture and then transected with cautery, with excellent hemostasis. The anterior bladder flap was then created by gentle and careful dissection of the uterus with assistance of metzenbaum scissors allowing the bladder to fall away from the uterus.
The left utero-ovarian ligament was then isolated with curved Heaney clamps and ligated first with a free tie, then re-enforced with suture ligation using 0 polysorb, the right utero-ovarian ligament was then ligated in a similar fashion. The left and right uterine vessels were carefully skelontonized, and isolated with curved Heaney clamps, and then suture ligated with 0 polysorb sutures with excellent hemostasis. The cervix was further disected away from the bladder. Straight Heaney clamps were used along the cervix to allow for further mobilization and were suture ligated with 0 polysorb with excellent hemostasis
The cervix was crossclamped with 2 curve Heaney clamps, and entire uterus was removed with 15 mm blade knife. The remaining vaginal cuff was closed with several figure of eight sutures. The remaining ligated pedicles were reinpected after irrigation with water with complete hemostasis found.
Attention was then turned to bilateral tubes. The right fimbria was clamped with a Peon clamp and removed using curved mayo scissors and secured with a free tie with excellent hemostasis. The left fimbria was removed in a similar fashion.
Gross inspection of the pelvis was done in attempts to identify an IUD. NO IUD was visualized. Prior to closure a KUB was obtained which did not visualize a remaining IUD.
After additional irrigation with water, the abdomen was closed in a routine fashion. 2-0 polysord to close the muscle with 2 interrupted mattress stitches, PDS suture was used to close the fascia layers, 3-0 polysorb was used to close the subcutaneous layer in an interrupted fashion. 4-0 biosyn suture was used to close the skin in a subcuticular fashion
Sponge, needle and instrument counts were reported to be correct. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
Foley was draining clear urine at the end of the procedure
All instruments were removed from the vagina. Vaginal sweep was done and found to be clear.
Thank YOU
I code 58180 but I feel something is missing.
Here is the scenario
OPEN ABDOMINAL ENTRY:
A midline abdominal incision was made 2 cm above the symphysis pubis .
Gross inspection of the pelvic reviewed a dense adhesions, obliterated anterior cul-de-sac, with uterus densely adherent to the anterior abdominal wall and bladder. Careful dissection of the uterus was completed via assistance of blunt dissection, mayo scissors and cautery.
The left and right round ligaments were identified and suture ligated with 0 polysorb suture and then transected with cautery, with excellent hemostasis. The anterior bladder flap was then created by gentle and careful dissection of the uterus with assistance of metzenbaum scissors allowing the bladder to fall away from the uterus.
The left utero-ovarian ligament was then isolated with curved Heaney clamps and ligated first with a free tie, then re-enforced with suture ligation using 0 polysorb, the right utero-ovarian ligament was then ligated in a similar fashion. The left and right uterine vessels were carefully skelontonized, and isolated with curved Heaney clamps, and then suture ligated with 0 polysorb sutures with excellent hemostasis. The cervix was further disected away from the bladder. Straight Heaney clamps were used along the cervix to allow for further mobilization and were suture ligated with 0 polysorb with excellent hemostasis
The cervix was crossclamped with 2 curve Heaney clamps, and entire uterus was removed with 15 mm blade knife. The remaining vaginal cuff was closed with several figure of eight sutures. The remaining ligated pedicles were reinpected after irrigation with water with complete hemostasis found.
Attention was then turned to bilateral tubes. The right fimbria was clamped with a Peon clamp and removed using curved mayo scissors and secured with a free tie with excellent hemostasis. The left fimbria was removed in a similar fashion.
Gross inspection of the pelvis was done in attempts to identify an IUD. NO IUD was visualized. Prior to closure a KUB was obtained which did not visualize a remaining IUD.
After additional irrigation with water, the abdomen was closed in a routine fashion. 2-0 polysord to close the muscle with 2 interrupted mattress stitches, PDS suture was used to close the fascia layers, 3-0 polysorb was used to close the subcutaneous layer in an interrupted fashion. 4-0 biosyn suture was used to close the skin in a subcuticular fashion
Sponge, needle and instrument counts were reported to be correct. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
Foley was draining clear urine at the end of the procedure
All instruments were removed from the vagina. Vaginal sweep was done and found to be clear.
Thank YOU