I would like some input on the correct procedure code and dx for this surgery.....
Pre-op Diagnosis: Trisomy 18
Post-op Diagnosis: Trisomy 18
Procedure: Suction Dilation and curettage
Indications: This patient has been following at our office, had an abnormal ultrasound, first trimester, referred to Maternal Fetal Medicine. CVS resulted in trisomy 18. The patient has request a D&C for treatment. She is brought in for that procedure. She is thought to be approx. 12 weeks. Uterus is about 9 to 10 week size.
Description: The patient was brought to the operating room where IV was started. General anesthesia was obtained. She was prepped and draped in high lithotomy. RhoGAM was given to her left side. Surgical pause was then done. Everyone was in agreement of the procedure. The laminaria had been taken out prior to prepping the patient. The cervix was grasped with a single-tooth tenaculum and was dilated to #13 Hegar. A #12 suction curettage was placed in the cavity, and the cavity was emptied. This was followed by sharp curettage and then once again by suction. Once again, the sharp curettage was used and the cavity felt clean. The specimen was then visualized and thought to be appropriate for this gestational size. All instruments were then removed. The patient was taken to recovery room in excellent condition. It should be noted that the uterus came down well with traction. Blood loss was figured to be approx. 30 mL
I'm thinking it should be 59840 with O35.1XX0, Z33.2, and Z3A.12
Pre-op Diagnosis: Trisomy 18
Post-op Diagnosis: Trisomy 18
Procedure: Suction Dilation and curettage
Indications: This patient has been following at our office, had an abnormal ultrasound, first trimester, referred to Maternal Fetal Medicine. CVS resulted in trisomy 18. The patient has request a D&C for treatment. She is brought in for that procedure. She is thought to be approx. 12 weeks. Uterus is about 9 to 10 week size.
Description: The patient was brought to the operating room where IV was started. General anesthesia was obtained. She was prepped and draped in high lithotomy. RhoGAM was given to her left side. Surgical pause was then done. Everyone was in agreement of the procedure. The laminaria had been taken out prior to prepping the patient. The cervix was grasped with a single-tooth tenaculum and was dilated to #13 Hegar. A #12 suction curettage was placed in the cavity, and the cavity was emptied. This was followed by sharp curettage and then once again by suction. Once again, the sharp curettage was used and the cavity felt clean. The specimen was then visualized and thought to be appropriate for this gestational size. All instruments were then removed. The patient was taken to recovery room in excellent condition. It should be noted that the uterus came down well with traction. Blood loss was figured to be approx. 30 mL
I'm thinking it should be 59840 with O35.1XX0, Z33.2, and Z3A.12