pclaybaugh
Networker
Greetings,
I code mostly OB deliveries and am revisiting Gyn Coding and have the following op report. Forgive the length. I have coded this with 58552. Please, am I missing something?
A sterile speculum was placed in the patient’s vagina and the cervix was visualized. A single tooth tenaculum was used to grasp the anterior lip of the cervix. The uterus was sounded to 9 cm. A 0-vicryl figure of eight stitch was placed at the 12:00 position and then secured to the V-care uterine manipulator, which was placed in the usual manner. The speculum was then removed from the vagina. Attention was then turned to the patient’s abdomen were a 5mm skin incision was made in the lower margin of the umbilicus after injection of local anesthesia. A 5mm trocar and sleeve were then carefully introduced into the peritoneal cavity under direct visualization at a 90-degree angle, while tenting up the abdominal wall. Intra-peritoneal placement was confirmed under direct visualization with the laparoscope with entry pressure <5 mm Hg. A pneumoperitoneum was obtained with CO2 gas and maximum pressure of 20 mmHg. Upon entry into the peritoneal cavity, structures immediately below the incision were inspected and found to be free of injury. Three additional port sites, including a 5mm left-lower quadrant x 2, a 5-mm right lower quadrant were placed under direct laparoscopic visualization. A survey of the pt’s abdomen and pelvis was notable for normal appearing liver edge and gall bladder. The appendix was not visualized. The ovaries were seen bilaterally and were normal in appearance. The fallopian tubes were normal in appearance bilaterally. The anterior cul de sac was normal in appearance. The posterior cul de sac was normal in appearance. There were no discreet endometriosis lesions seen in the pelvis. The ureters were then identified bilaterally coursing along the lateral pelvic sidewalls. Stabilizing the uterus with the manipulator, the Ligasure was used ligate the mesosalpinx under the fallopian tube on the left. The procedure was repeated on the right side. The fallopian tubes remained attached to the uterine fundus. The Ligasure was then used to clamp, cut, and ligate the round ligaments bilaterally. The anterior broad ligament was then incised along the bladder reflection starting on the right side and carried around to the left side. The bladder was dissected off the lower uterine segment until endopelvic fascia was visualized.The utero-ovarian ligaments were then ligated as close as possible to the uterine corpus with the Ligasure.The pedicles were then inspected, with hemostasis noted.The uterine arteries were then identified, skeletonized, electro-dessicated and ligated using Ligasure electrocautery.The uterosacral ligaments and cardinal ligaments were transected bilaterally using Ligasure. The anterior colpotomy was then made using the Ligasure hook.The colpotomy was then continued circumferentially just inferior to the cervix using the V-care® colpotomy ring as a guide.The entire cervix and uterus was then successfully amputated from the vagina.Hemostasis was noted.The uterus, fallopian tubes, and cervix were then delivered through the vagina.The vagina was occluded with an aseptic bulb with ratex inside on a ring forceps. The vaginal cuff was closed laparoscopically with running V-Loc suture. The uterosacral ligament was incorporated on the right side. To the right of midline the suture broke off the needle. The needle was removed via Left lower quadrant port. A second V-Loc suture was place into the abdomen. The suture was oversewn through the midline. The cuff was closed and the second needle removed from the abdomen. The pelvis was irrigated. The vaginal cuff and pedicles were noted to be hemostatic. The vaginal occluder was then removed. The cystoscope was then primed and advanced through the urethra and into the bladder. Both ureteral orifices were identified and bilateral efflux of urine visualized. A survey of bladder showed no defects or visible suture. The cystoscope was then removed and the bladder drained. A vaginal exam was completed without cuff defect noted. The cuff was well suspended. All instruments were noted to be removed from the vagina.
I code mostly OB deliveries and am revisiting Gyn Coding and have the following op report. Forgive the length. I have coded this with 58552. Please, am I missing something?
A sterile speculum was placed in the patient’s vagina and the cervix was visualized. A single tooth tenaculum was used to grasp the anterior lip of the cervix. The uterus was sounded to 9 cm. A 0-vicryl figure of eight stitch was placed at the 12:00 position and then secured to the V-care uterine manipulator, which was placed in the usual manner. The speculum was then removed from the vagina. Attention was then turned to the patient’s abdomen were a 5mm skin incision was made in the lower margin of the umbilicus after injection of local anesthesia. A 5mm trocar and sleeve were then carefully introduced into the peritoneal cavity under direct visualization at a 90-degree angle, while tenting up the abdominal wall. Intra-peritoneal placement was confirmed under direct visualization with the laparoscope with entry pressure <5 mm Hg. A pneumoperitoneum was obtained with CO2 gas and maximum pressure of 20 mmHg. Upon entry into the peritoneal cavity, structures immediately below the incision were inspected and found to be free of injury. Three additional port sites, including a 5mm left-lower quadrant x 2, a 5-mm right lower quadrant were placed under direct laparoscopic visualization. A survey of the pt’s abdomen and pelvis was notable for normal appearing liver edge and gall bladder. The appendix was not visualized. The ovaries were seen bilaterally and were normal in appearance. The fallopian tubes were normal in appearance bilaterally. The anterior cul de sac was normal in appearance. The posterior cul de sac was normal in appearance. There were no discreet endometriosis lesions seen in the pelvis. The ureters were then identified bilaterally coursing along the lateral pelvic sidewalls. Stabilizing the uterus with the manipulator, the Ligasure was used ligate the mesosalpinx under the fallopian tube on the left. The procedure was repeated on the right side. The fallopian tubes remained attached to the uterine fundus. The Ligasure was then used to clamp, cut, and ligate the round ligaments bilaterally. The anterior broad ligament was then incised along the bladder reflection starting on the right side and carried around to the left side. The bladder was dissected off the lower uterine segment until endopelvic fascia was visualized.The utero-ovarian ligaments were then ligated as close as possible to the uterine corpus with the Ligasure.The pedicles were then inspected, with hemostasis noted.The uterine arteries were then identified, skeletonized, electro-dessicated and ligated using Ligasure electrocautery.The uterosacral ligaments and cardinal ligaments were transected bilaterally using Ligasure. The anterior colpotomy was then made using the Ligasure hook.The colpotomy was then continued circumferentially just inferior to the cervix using the V-care® colpotomy ring as a guide.The entire cervix and uterus was then successfully amputated from the vagina.Hemostasis was noted.The uterus, fallopian tubes, and cervix were then delivered through the vagina.The vagina was occluded with an aseptic bulb with ratex inside on a ring forceps. The vaginal cuff was closed laparoscopically with running V-Loc suture. The uterosacral ligament was incorporated on the right side. To the right of midline the suture broke off the needle. The needle was removed via Left lower quadrant port. A second V-Loc suture was place into the abdomen. The suture was oversewn through the midline. The cuff was closed and the second needle removed from the abdomen. The pelvis was irrigated. The vaginal cuff and pedicles were noted to be hemostatic. The vaginal occluder was then removed. The cystoscope was then primed and advanced through the urethra and into the bladder. Both ureteral orifices were identified and bilateral efflux of urine visualized. A survey of bladder showed no defects or visible suture. The cystoscope was then removed and the bladder drained. A vaginal exam was completed without cuff defect noted. The cuff was well suspended. All instruments were noted to be removed from the vagina.
