natashalage
Expert
Hello Fellow Coders, I am new to OB/GYN and got very puzzled by this short Op note: trying to understand what was done to match CPT available. I will greatly appreciate your help!
MD provided codes 57260 and 57282. I read the descriptions of all available CPT, I googled a lot about POP, compiled some information but nothing has helped me to find straight-forward CPT. It even does not tell me what organ has prolapsed, just the stage. It seems like the only 57282 was done. Thank you very much. in advance.
MD provided codes 57260 and 57282. I read the descriptions of all available CPT, I googled a lot about POP, compiled some information but nothing has helped me to find straight-forward CPT. It even does not tell me what organ has prolapsed, just the stage. It seems like the only 57282 was done. Thank you very much. in advance.
MD put 57260 anterior and posterior colporrhaphy+ 57282 colpopexy vaginal sacrospinous aproach
Procedure(s) and Anesthesia Type:
* ANTERIOR COLPORRHAPHY - Anes-General =57240 but it was not done
* CYSTOSCOPY (CYSTOURETHROSCOPY) - Anes-General = I found it is included into 57260-57265= don’t code it
* CYSTOSCOPY, SACROSPINOUS COLPOPEXY - Anes-General = 57282
Clinical Indications
1. Symptomatic stage III POP
Findings
1. Ba to +3 with excellent support of all vaginal compartments with apical suspension using scopette. Normal vaginal epithelium without masses, lesions or bleeding.
Detailed Description of Procedure:
Opening:
After appropriate consents were signed, patient was brought to the operating room and a surgical time out was performed, and general anesthesia was obtained without difficulty. She received 2 grams of IV Ancef for SSI prophylaxis. The patient was placed in the dorsal lithotomy position, with legs in Candy Cane stirups and SCDs on and active. Arms and legs positioned and padded to prevent nerve palsy. The patient was prepped and draped in a sterile fashion.
Sacrospinous ligament fixation: 57282 agree
The vaginal cuff was identified, everted and grasped with Allis clamps. The epithelium was entered sharply with Metzenbaum scissors. A 2 cm x 2 cm section of underlying fisbromuscular tissue was exposed. Next the right ischial spine was identified by palpation. The retroperitoneum was entered sharply, and a tunnel was created to the spine with blunt dissection. Care was taken to gently sweep the rectum posterior and medial, away from the operative field. The sacrospinous ligament and coccygeus muscle were then isolated with blunt dissection. A Capio suture device was used to place 2 stitches of 0-PDS, through the sacrospinous ligament, 2 cm medial to the ischial spine, avoiding the pudendal neurovascular bundle. A rectal exam confirmed proper placement, with no suture in the rectum. The sutures were clamped and placed to the side.
Anterior repair: 57240 does not match the description.
The anterior vagina was incised in the midline from the vaginal cup, to 3 cm cephalad of the hymenal ring. The vaginal mucosa was dissected off of the underlying fibromuscular layer. Excess vaginal mucosa was trimmed off. The underlying fibromuscular layer was plicated with a series of imbricating stitches, starting with 0-pds suture. Next, the vaginal mucosa was re-approximated in a running-locked stitch of of 0-Vicryl. At this point, the suspension sutures were passed through the anterior portion of vaginal cuff. The PDS suture was placed beneath the vaginal epithelium, in the fibromuscular layer. Next the suspension sutures were secured, suspending the vaginal apex to the sacrospinous ligament. Care was taken to remove the extra slack in the suture, without placing the suture on too much tension. Excellent hemostasis was noted.