Good morning!
I am looking for some assistance in how to bill this procedure out correctly. The office has two differing opinions on how this should be billed. I have included the OP report below if someone can help me out.
Thank you in advance!
Name of Operation
Total vaginal hysterectomy
Laparoscopic bilateral salpingo-oophorectomy
Cystoscopy
Description of Operation Performed, Including Technique
The patient was taken to the operating room where general anesthesia was obtained. She was positioned in dorsal lithotomy and an exam under anesthesia was performed. She was prepped and draped in the usual sterile fashion. A foley catheter was placed. A weighted speculum was placed in the vagina. The cervix was grasped with a tenaculum. Lidocaine with epi was injected in the cervix which was then incised circumferentially. The vaginal tissue was dissected off the cervix to displace the bladder cephalad. The posterior cul de sac was entered sharply. No adhesions were encountered on digital exploration. A long speculum was replaced to protect the rectum. With the bladder displaced, bilateral uterosacral ligaments were grasped, transected, suture ligated with 0 Vicryl, and tagged for subsequent incorporation into closure.
Anterior colpotomy was then made sharply and a dever was placed to protect the bladder. Bilateral uterine arteries, cardinal ligaments, and utero-ovarian vessels were serially grasped, ligated, and transected with a combination of 0 Vicryl and Ligasure. Due to the bulk of the uterus towards the fundus, there was not enough space to adequately visualize and transect the cornua. The decision was made to bivalve the uterus. A malleable was placed to protect intraabdominal contents while the uterus was bivalved with a scalpel and subsequently scissors. Unexpectedly the right hemiuterus delivered after the fundus was transected. It was passed off the field. The left hemiuterus was delivered until the cornua was easily palpable. The round ligament and proximal tube were cauterized and transected with the Ligasure. The hemiuterus was delivered and passed off the field. Attention was turned to the right pelvic sidewall as we had not cauterized and divided the pedicles there. There was slow active bleeding from high on the pelvic side wall. As the tubes and ovaries were not accessible vaginally and adequate visualization of the source of bleeding on the right pelvic sidewall could not be visualized, the decision was made to proceed laparoscopically. A lap sponge in a glove was placed in the vagina.
She was reprepped and draped in the usual sterile fashion. A 5mm incision was made just above the umbilicus. A 5 mm trocar was placed with the camera under direct visualization. Once intraperitoneal placement was confirmed, pneumoperitoneum was obtained to 15 mm Hg. A diagnostic laparoscopy was completed with no evidence of injury. A 5 mm operative trocar was placed in the LLQ. A 5 mm operative trocar was placed in the RLQ. The right pelvic side wall was examined and the source of bleeding was noted to be the round ligament. This was grasped with the Ligasure and cauterized with good hemostasis noted. The right ovary was elevated off the side wall and the IP ligament was doubly cauterized then divided distally. The mesosalpinx was serially cauterized and divided. The right tube and ovary were passed out through the vagina. The same procedure was performed on the other side. The pelvis was irrigated. The pressure was dropped and continued hemostasis noted. Surgicel powder was placed in the operative field. The pressure was released. All trocars and instruments were removed from the abdomen. The incisions were closed with 4-0 Vicryl and Dermabond.
The cuff was closed with 0 Vicryl in running fashion, with care to incorporate the tagged uterosacral ligament. Cystoscopy was performed which showed brisk bilateral ureteral efflux and no bladder injury.
Good hemostasis was noted. All instruments were removed. The patient was awoken from anesthesia and taken to the recovery room in stable condition.
Description of Any Drains, Catheters, or Packing Left in Place
Foley catheter
Findings
Large cervix
Normal right ovary, atrophic left ovary
Normal liver edge and gallbladder
Specimen(s)
Uterus and cervix
Bilateral tubes and ovaries
Complications
Inability to complete procedure vaginally as planned
I am looking for some assistance in how to bill this procedure out correctly. The office has two differing opinions on how this should be billed. I have included the OP report below if someone can help me out.
Thank you in advance!
Name of Operation
Total vaginal hysterectomy
Laparoscopic bilateral salpingo-oophorectomy
Cystoscopy
Description of Operation Performed, Including Technique
The patient was taken to the operating room where general anesthesia was obtained. She was positioned in dorsal lithotomy and an exam under anesthesia was performed. She was prepped and draped in the usual sterile fashion. A foley catheter was placed. A weighted speculum was placed in the vagina. The cervix was grasped with a tenaculum. Lidocaine with epi was injected in the cervix which was then incised circumferentially. The vaginal tissue was dissected off the cervix to displace the bladder cephalad. The posterior cul de sac was entered sharply. No adhesions were encountered on digital exploration. A long speculum was replaced to protect the rectum. With the bladder displaced, bilateral uterosacral ligaments were grasped, transected, suture ligated with 0 Vicryl, and tagged for subsequent incorporation into closure.
Anterior colpotomy was then made sharply and a dever was placed to protect the bladder. Bilateral uterine arteries, cardinal ligaments, and utero-ovarian vessels were serially grasped, ligated, and transected with a combination of 0 Vicryl and Ligasure. Due to the bulk of the uterus towards the fundus, there was not enough space to adequately visualize and transect the cornua. The decision was made to bivalve the uterus. A malleable was placed to protect intraabdominal contents while the uterus was bivalved with a scalpel and subsequently scissors. Unexpectedly the right hemiuterus delivered after the fundus was transected. It was passed off the field. The left hemiuterus was delivered until the cornua was easily palpable. The round ligament and proximal tube were cauterized and transected with the Ligasure. The hemiuterus was delivered and passed off the field. Attention was turned to the right pelvic sidewall as we had not cauterized and divided the pedicles there. There was slow active bleeding from high on the pelvic side wall. As the tubes and ovaries were not accessible vaginally and adequate visualization of the source of bleeding on the right pelvic sidewall could not be visualized, the decision was made to proceed laparoscopically. A lap sponge in a glove was placed in the vagina.
She was reprepped and draped in the usual sterile fashion. A 5mm incision was made just above the umbilicus. A 5 mm trocar was placed with the camera under direct visualization. Once intraperitoneal placement was confirmed, pneumoperitoneum was obtained to 15 mm Hg. A diagnostic laparoscopy was completed with no evidence of injury. A 5 mm operative trocar was placed in the LLQ. A 5 mm operative trocar was placed in the RLQ. The right pelvic side wall was examined and the source of bleeding was noted to be the round ligament. This was grasped with the Ligasure and cauterized with good hemostasis noted. The right ovary was elevated off the side wall and the IP ligament was doubly cauterized then divided distally. The mesosalpinx was serially cauterized and divided. The right tube and ovary were passed out through the vagina. The same procedure was performed on the other side. The pelvis was irrigated. The pressure was dropped and continued hemostasis noted. Surgicel powder was placed in the operative field. The pressure was released. All trocars and instruments were removed from the abdomen. The incisions were closed with 4-0 Vicryl and Dermabond.
The cuff was closed with 0 Vicryl in running fashion, with care to incorporate the tagged uterosacral ligament. Cystoscopy was performed which showed brisk bilateral ureteral efflux and no bladder injury.
Good hemostasis was noted. All instruments were removed. The patient was awoken from anesthesia and taken to the recovery room in stable condition.
Description of Any Drains, Catheters, or Packing Left in Place
Foley catheter
Findings
Large cervix
Normal right ovary, atrophic left ovary
Normal liver edge and gallbladder
Specimen(s)
Uterus and cervix
Bilateral tubes and ovaries
Complications
Inability to complete procedure vaginally as planned
