Need some help with this one. Fairly new to OB/GYN. I come up with:
58120 and 44180. 44180 is a seperate procedure, but this op report supports the code. Dx is endometrial thickening and RLQ pain, hx of salpingo-oophorectomy.
PREOPERATIVE DIAGNOSES:
1. Perimenopausal bleeding with endometrial thickening.
2. Right lower quadrant abdominal pain.
3. History of prior left salpingo-oophorectomy--2008.
POSTOPERATIVE DIAGNOSES:
1. Perimenopausal bleeding with endometrial thickening.
2. Right lower quadrant abdominal pain.
3. History of prior left salpingo-oophorectomy--2008.
4. Intraabdominal adhesions.
PROCEDURES PERFORMED:
1. Diagnostic laparoscopy.
2. Laparoscopic adhesiolysis.
3. Diagnostic hysteroscopy.
4. Fractional dilation and curettage.
ANESTHESIA: General per endotracheal tube.
ANESTHESIOLOGIST:
ESTIMATED BLOOD LOSS: Less than 10 mL.
DRAINS: None.
COMPLICATIONS: None.
SPECIMENS:
1. Endocervical and endometrial curettings submitted separately:
2. Pelvic washings.
FINDINGS:
1. A stenotic cervix.
2. Uterus sounded to 7 cm and retroverted.
3. Normal-appearing endometrial cavity without evidence of lesions, masses or
hyperplasia.
4. Benign-appearing endometrium.
5. Retroverted normal size and appearance of the uterus.
6. Normal anterior and posterior cul-de-sac.
7. Absence of left fallopian tube and ovary consistent with prior surgery.
8. Normal-appearing right tube and ovary without evidence of adhesions,
endometriosis or other abnormalities seen by prior tubal ligation via Falope
ring noted.
9. Adhesions of the ascending colon and omentum to the right lateral abdominal
wall.
10. Normal-appearing appendix.
11. Otherwise, normal-appearing upper abdominal contents.
IDENTIFYING DATA: The patient is a very pleasant 51-year-old Caucasian female
gravida 3, para 1-0-2-1, perimenopausal times one year, admitted for abdominal
pain on July 17, 2012, by her primary physician, I was
requested to see the patient in consultation because of perimenopausal bleeding
and thickened endometrium of 14.7 mm. I was covering for the patient's
gynecologist Dr. who is unavailable this week.
Subsequent CT scan of the abdomen and pelvis revealed no other abnormalities.
Because of her persistent right lower quadrant pain, history of perimenopausal
bleeding and thickened endometrium, decision to proceed with fractional
dilation and curettage, diagnostic hysteroscopy, diagnostic laparoscopy,
possible oophorectomy and possible hysterectomy was made. The options for
management were reviewed with the patient. She has consented to treatment plan
as such.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where
time-out was called. She identified herself as the patient, me as a surgeon
and procedure to be performed as those listed on her consent form. General
anesthesia was then induced per endotracheal tube per Dr. without
difficulty. She was placed in dorsal lithotomy position, prepped and draped in
normal fashion. Exam under anesthesia revealed a stenotic cervix, retroverted,
normal size uterus without palpable right adnexal enlargement. Single-tooth
tenaculum was placed in anterior lip of the cervix and the cervix was dilated
to number 16 and a cervical curettings were obtained and submitted separately.
Uterus was sounded to 7 cm and noted to be retroverted 5 mm. Hysteroscope was
then placed and 1.5% glycerin solution was used to visualize the endometrial
cavity. Endometrial cavity appeared normal without evidence of masses,
lesions, polyps or hyperplastic appearing endometrium. Minimal to moderate
amount of endometrium was noted. Hysteroscope was removed. Endometrial
curettings were obtained and submitted separately. Uterine manipulator was
inserted in the cervical os and attached to previously placed tenaculum.
Attention was then turned to the abdomen where a transverse subumbilical skin
incision was made at the site of prior laparoscopic incision site and incision
was carried down through subcutaneous fat, fascia and underlying peritoneum,
all of which were opened sharply under direct visualization. 0 Vicryl
retention sutures were placed on the fascia and some laparoscopic sheath and
blunt trocar were introduced. Pneumoperitoneum was created to 15 mmHg after
insufflation with 3.5 liters of carbon dioxide gas. A 5-mm sheath and trocar
were introduced in the lower abdomen under direct visualization of laparoscope.
The pelvis and upper abdominal contents were inspected and findings were as
listed above under findings. The adhesions of the omentum to the ascending
colon and right lateral abdominal wall were noted, taken down by sharp and
blunt dissection with a gyrus instrument as well as hydrodissection. The
appendix appeared normal and the remainder of the upper abdominal contents
appeared normal as did the anterior and posterior cul-de-sac, the uterus
itself, the right fallopian tube and the right ovary. The cervical and vaginal
instruments were then removed. Abdominal instruments were removed. Carbon
dioxide gas allowed to passively diffuse from the abdomen and the abdominal
incision sites closed in multiple layers including 0 Vicryl in interlocking
fashion to approximate the fascia, 4-0 Vicryl in a simple interrupted fashion
was used to approximate the subcuticular skin edges. Octylseal skin adhesive
was used to approximate skin edges of both lower and the subumbilical incision
site. Cervical and vaginal instruments were then removed. The Foley catheter
was removed. The patient was placed back in supine position, reversed from
general anesthesia, returned to recovery room in stable condition with correct
sponge, needle and instrument count as reported to me by the nursing staff.
Thank you,
Brendan Bailey, CPC
58120 and 44180. 44180 is a seperate procedure, but this op report supports the code. Dx is endometrial thickening and RLQ pain, hx of salpingo-oophorectomy.
PREOPERATIVE DIAGNOSES:
1. Perimenopausal bleeding with endometrial thickening.
2. Right lower quadrant abdominal pain.
3. History of prior left salpingo-oophorectomy--2008.
POSTOPERATIVE DIAGNOSES:
1. Perimenopausal bleeding with endometrial thickening.
2. Right lower quadrant abdominal pain.
3. History of prior left salpingo-oophorectomy--2008.
4. Intraabdominal adhesions.
PROCEDURES PERFORMED:
1. Diagnostic laparoscopy.
2. Laparoscopic adhesiolysis.
3. Diagnostic hysteroscopy.
4. Fractional dilation and curettage.
ANESTHESIA: General per endotracheal tube.
ANESTHESIOLOGIST:
ESTIMATED BLOOD LOSS: Less than 10 mL.
DRAINS: None.
COMPLICATIONS: None.
SPECIMENS:
1. Endocervical and endometrial curettings submitted separately:
2. Pelvic washings.
FINDINGS:
1. A stenotic cervix.
2. Uterus sounded to 7 cm and retroverted.
3. Normal-appearing endometrial cavity without evidence of lesions, masses or
hyperplasia.
4. Benign-appearing endometrium.
5. Retroverted normal size and appearance of the uterus.
6. Normal anterior and posterior cul-de-sac.
7. Absence of left fallopian tube and ovary consistent with prior surgery.
8. Normal-appearing right tube and ovary without evidence of adhesions,
endometriosis or other abnormalities seen by prior tubal ligation via Falope
ring noted.
9. Adhesions of the ascending colon and omentum to the right lateral abdominal
wall.
10. Normal-appearing appendix.
11. Otherwise, normal-appearing upper abdominal contents.
IDENTIFYING DATA: The patient is a very pleasant 51-year-old Caucasian female
gravida 3, para 1-0-2-1, perimenopausal times one year, admitted for abdominal
pain on July 17, 2012, by her primary physician, I was
requested to see the patient in consultation because of perimenopausal bleeding
and thickened endometrium of 14.7 mm. I was covering for the patient's
gynecologist Dr. who is unavailable this week.
Subsequent CT scan of the abdomen and pelvis revealed no other abnormalities.
Because of her persistent right lower quadrant pain, history of perimenopausal
bleeding and thickened endometrium, decision to proceed with fractional
dilation and curettage, diagnostic hysteroscopy, diagnostic laparoscopy,
possible oophorectomy and possible hysterectomy was made. The options for
management were reviewed with the patient. She has consented to treatment plan
as such.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where
time-out was called. She identified herself as the patient, me as a surgeon
and procedure to be performed as those listed on her consent form. General
anesthesia was then induced per endotracheal tube per Dr. without
difficulty. She was placed in dorsal lithotomy position, prepped and draped in
normal fashion. Exam under anesthesia revealed a stenotic cervix, retroverted,
normal size uterus without palpable right adnexal enlargement. Single-tooth
tenaculum was placed in anterior lip of the cervix and the cervix was dilated
to number 16 and a cervical curettings were obtained and submitted separately.
Uterus was sounded to 7 cm and noted to be retroverted 5 mm. Hysteroscope was
then placed and 1.5% glycerin solution was used to visualize the endometrial
cavity. Endometrial cavity appeared normal without evidence of masses,
lesions, polyps or hyperplastic appearing endometrium. Minimal to moderate
amount of endometrium was noted. Hysteroscope was removed. Endometrial
curettings were obtained and submitted separately. Uterine manipulator was
inserted in the cervical os and attached to previously placed tenaculum.
Attention was then turned to the abdomen where a transverse subumbilical skin
incision was made at the site of prior laparoscopic incision site and incision
was carried down through subcutaneous fat, fascia and underlying peritoneum,
all of which were opened sharply under direct visualization. 0 Vicryl
retention sutures were placed on the fascia and some laparoscopic sheath and
blunt trocar were introduced. Pneumoperitoneum was created to 15 mmHg after
insufflation with 3.5 liters of carbon dioxide gas. A 5-mm sheath and trocar
were introduced in the lower abdomen under direct visualization of laparoscope.
The pelvis and upper abdominal contents were inspected and findings were as
listed above under findings. The adhesions of the omentum to the ascending
colon and right lateral abdominal wall were noted, taken down by sharp and
blunt dissection with a gyrus instrument as well as hydrodissection. The
appendix appeared normal and the remainder of the upper abdominal contents
appeared normal as did the anterior and posterior cul-de-sac, the uterus
itself, the right fallopian tube and the right ovary. The cervical and vaginal
instruments were then removed. Abdominal instruments were removed. Carbon
dioxide gas allowed to passively diffuse from the abdomen and the abdominal
incision sites closed in multiple layers including 0 Vicryl in interlocking
fashion to approximate the fascia, 4-0 Vicryl in a simple interrupted fashion
was used to approximate the subcuticular skin edges. Octylseal skin adhesive
was used to approximate skin edges of both lower and the subumbilical incision
site. Cervical and vaginal instruments were then removed. The Foley catheter
was removed. The patient was placed back in supine position, reversed from
general anesthesia, returned to recovery room in stable condition with correct
sponge, needle and instrument count as reported to me by the nursing staff.
Thank you,
Brendan Bailey, CPC