PICFLORIDA49
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--------------------------------------------------------------------------------I need help coding the control of hemorrhage for this patient. Here is the operative report: OPERATIVE PROCEDURE: The patient was taken to operating room where a vaginal prep was done. She was in the lithotomy position. General anesthesia had been given. A posterior weighted speculum was placed within the vagina. The anterior lip of the cervix was grasped with an Allis. There was a moderately bleeding area seen at the 2 o'clock position, and this was cauterized immediately with good hemostasis. There were other areas also oozing bright red blood. These were treated at 10 o'clock and along the posterior aspect of LEEP site as well. Overall, there appeared to be decent hemostasis. As a precaution, I wanted to check the endocervical canal. I placed the blunt end of a Q-Tip within it. After this, brisk bleeding was encountered. Therefore, cautery was used in a circumferential fashion in the endocervical canal blindly to control this. After doing this on 2 separate occasions, bleeding risk was much, much improved. It was scant at this point. Since this is a return to OR, to help ensure no further bleeding, I placed U-stitches from 12 o'clock to 3 o'clock, 3-6 o'clock, 6-9, and 9-12 o'clock as well to help with hemostasis. Then, good hemostasis was seen to remain. As an additional precaution, a piece of Surgicel was placed at the bed of the LEEP site after this, and tied in place with a #0 Vicryl stitch. All instruments were removed from the vagina at that point. Two minutes went by. After this, I rechecked the site, to ensure that she remained hemostatic. It appears that she is hemostatic at this point. Therefore, the procedure was ended. She was awaken from her anesthesia and taken to recovery in stable condition. Counts were correct.
Thank you for any help you can provide.