Hello everyone,
We're really stuck on this procedure and cant figure out what CPT codes would apply, any help would be greatly appreciated.
PREOP DIAGNOSIS:
Pelvic pain with intrauterine pelvic mass
PROCEDURES:
Exam under anesthesia, hysteroscopy, endometrial biopsy, and partial resection of endometrial fibroid with MyoSure; laparoscopy, ablation of endometriosis.
PROCEDURE IN DETAIL:
She had signed an informed consent and prepped and draped in normal fashion and placed in dorsal lithotomyposition. she had been given 1g of Ancef prior to surgery. The perineum was prepped and with a small speculum the cervix was visualized. The vaginal cavity was normal. The cervix was grasped with a single tooth tenaculum and then dilated with Hanks and then Pratt dilators. Initially, the hysteroscope was placed in with ultrasound guidance.
The left-sided pelvic mass was noted. It appeared to be separated from the
pelvic cavity and more on the left side of the uterus itself, but it was not
pedunculated. Because of this, comes to biopsy the area, were unsuccessful
because there appeared to be a solid mass and because of this and because of her pelvic pain, a MyoSure was used and partially resected this mass, which was then sent to the pathology. Because-of-difficlilty- wit~vis~al-ization, the whole mass could not be separated." It should be noted that a Foley had been placed inside her bladder for drainage after this. The abdomen was then addressed. A marking was injected into the periumbilical area and incision was made. The abdomen was then insufflated with C02 to approximately 2.5 L and under direct visualization, a trocar and a 5 mm scope was then placed.
Two other side ports, with this the gas was then reattached and the uterus was visualized. Two other side ports were then placed and without difficulty and under direct visualization, they were 5 mm, and it should be noted that there was endometriosis on the right pelvic wall, posterior to the uterus, as the uterus was also hypervascular. On the left pelvic wall, there was additional signs of endometriosis. Using the bipolar cautery, these were ablated. The uterus itself was hypervascular and with light touch cautery, the
hypervascularity was ablated. The appendix was visualized and was normal.
The liver edge was visualized, was normal. The posterior under the uterus was suctioned and this was normal. Following this under direct visualization, the side ports were removed. The scope was removed and the ports were closed with 4-0 Prolene and the port for the incision of the scope was then closed using the glue stick. A bandage was then placed over the sutures and the patient was taken out of the dorsal lithotomy position. The Foley was removed. The trocar was removed and the patient was taken to recovery in satisfactory condition.
Thank you for any guidance anybody can provide.
We're really stuck on this procedure and cant figure out what CPT codes would apply, any help would be greatly appreciated.
PREOP DIAGNOSIS:
Pelvic pain with intrauterine pelvic mass
PROCEDURES:
Exam under anesthesia, hysteroscopy, endometrial biopsy, and partial resection of endometrial fibroid with MyoSure; laparoscopy, ablation of endometriosis.
PROCEDURE IN DETAIL:
She had signed an informed consent and prepped and draped in normal fashion and placed in dorsal lithotomyposition. she had been given 1g of Ancef prior to surgery. The perineum was prepped and with a small speculum the cervix was visualized. The vaginal cavity was normal. The cervix was grasped with a single tooth tenaculum and then dilated with Hanks and then Pratt dilators. Initially, the hysteroscope was placed in with ultrasound guidance.
The left-sided pelvic mass was noted. It appeared to be separated from the
pelvic cavity and more on the left side of the uterus itself, but it was not
pedunculated. Because of this, comes to biopsy the area, were unsuccessful
because there appeared to be a solid mass and because of this and because of her pelvic pain, a MyoSure was used and partially resected this mass, which was then sent to the pathology. Because-of-difficlilty- wit~vis~al-ization, the whole mass could not be separated." It should be noted that a Foley had been placed inside her bladder for drainage after this. The abdomen was then addressed. A marking was injected into the periumbilical area and incision was made. The abdomen was then insufflated with C02 to approximately 2.5 L and under direct visualization, a trocar and a 5 mm scope was then placed.
Two other side ports, with this the gas was then reattached and the uterus was visualized. Two other side ports were then placed and without difficulty and under direct visualization, they were 5 mm, and it should be noted that there was endometriosis on the right pelvic wall, posterior to the uterus, as the uterus was also hypervascular. On the left pelvic wall, there was additional signs of endometriosis. Using the bipolar cautery, these were ablated. The uterus itself was hypervascular and with light touch cautery, the
hypervascularity was ablated. The appendix was visualized and was normal.
The liver edge was visualized, was normal. The posterior under the uterus was suctioned and this was normal. Following this under direct visualization, the side ports were removed. The scope was removed and the ports were closed with 4-0 Prolene and the port for the incision of the scope was then closed using the glue stick. A bandage was then placed over the sutures and the patient was taken out of the dorsal lithotomy position. The Foley was removed. The trocar was removed and the patient was taken to recovery in satisfactory condition.
Thank you for any guidance anybody can provide.
