Missy13
Networker
Hello, I am not very experienced GYN coder. Attached is the surgery report before I get asked about it. Is this an extensive procedure? Can it be coded 58150 -22 ? I am just anxious when it comes to modifier 22.
The procedure was: Total abdominal hysterectomy with bilateral oophorectomy and right salpingectomy, lysis of adhesions.
Please Help
.... Pean clamp was then placed to the left round ligamentand then this was sharplytransected using mayo scissors and then in the standard manner suture ligated and transfixed. Pedicle was hemostatic. This was repeated on the opposite side. Next, on the left side the anterior peritoneal reflection was quited easy to create and it was done so using the Mayo scissors and carried down to the midlineabove the bladder: however on the opposite side it was slightly more difficultand extensive dissection was performed to create the portion of the bladder flap. Next the right fallopian tube and right ovary were identified.A window was created in the broad ligament to entrap the infundibulopelvic ligament on the right and transection was performed above the level of the curved Haney clamp. This was then suture ligated with a transfixed and with a free tie. This was repeated on the opposite side. Both pedicles were hemostatic.Both ovaries were still attached to the uterus; however, due to difficulties with exposure, the right tube and ovary were dissected off the uterus and handed off as a specimen. there was difficulty mobilizing and skeletonizing the uterine vessels so multiple attempts were made at each site using curvedHeaney clamps to crossclamp, sharply dissect using mayos and then suture ligate in a standard manner to get down towards the cardinal ligaments. Multiple perforating vessels were noted and hemostasis was assured with first hemostatsand then fee ties every time bleeding would be encauntered. The bladder exposure was difficult and multiple sponge sticks were used to dissect the bladder off of the servix. When Anesthesia notified the surgeons that the urine appeared slghtly blood-tinged, the bladder was retrofilled with sterile formula and methylene blue to identify if there was any intraoperative urine leak. None was noted.No blue or beige liquid was noted in the operaticve field. The bladder was then deflated and the surgery was continued. Eventually, the cardinal ligament was almost completely clamped on both sides. At this point decision was made to amputate the body of the uterus and then complete the ___ afterwards. The specimen was handed off and then suregon's attention was turned to excising the cervical tissue. Kocher clamps were placed to the 4 apices of the cervix to the anterior, posterior and lateral aspect. The cervix was elevated and again curved Heaney clamps were used to continue to cross clampon the lateral aspect of the cervix until the vagina was reached. Once the vagina was reahced , it was entered sharply using the Mayo scissors and then incision was carried all the way around the circumferential manner. The cervical stump was reexamined once it was excised and it was noted that the enitre cervical tissue was removed and only the vaginal tissue remained at this point. The vagina was identified and interrupted figure-of-eightsutures were placed for closure of the vagina. There are multiple areas that were oozing and so additional figure-of-eight sutures were placed. Pressure was held multiple times to the area, however, the oozing continued. sprey thrombin and Gelfoam were used in the normal sterile fashion, 1 was soaked in the thrombin and then placed intactto the area and then second subsequent piece of just plain gelfoam was placed above that. The area did appear heostatic. The urine continued to remain slightly blood-tinged, however, there was no active extravasation into the field. Allother pedicles were examined and were noted to be hemostatic.t this point the decision was made to remove self-retainig retractor, to remove all of the lap sponges from the abdominal and pelvic cavity which were used to tamponade some of the bleeding and hold the bowel out of the way and further surve was conducted of the pelvis. ...... and the rest of report was just the closures.
The procedure was: Total abdominal hysterectomy with bilateral oophorectomy and right salpingectomy, lysis of adhesions.
Please Help
.... Pean clamp was then placed to the left round ligamentand then this was sharplytransected using mayo scissors and then in the standard manner suture ligated and transfixed. Pedicle was hemostatic. This was repeated on the opposite side. Next, on the left side the anterior peritoneal reflection was quited easy to create and it was done so using the Mayo scissors and carried down to the midlineabove the bladder: however on the opposite side it was slightly more difficultand extensive dissection was performed to create the portion of the bladder flap. Next the right fallopian tube and right ovary were identified.A window was created in the broad ligament to entrap the infundibulopelvic ligament on the right and transection was performed above the level of the curved Haney clamp. This was then suture ligated with a transfixed and with a free tie. This was repeated on the opposite side. Both pedicles were hemostatic.Both ovaries were still attached to the uterus; however, due to difficulties with exposure, the right tube and ovary were dissected off the uterus and handed off as a specimen. there was difficulty mobilizing and skeletonizing the uterine vessels so multiple attempts were made at each site using curvedHeaney clamps to crossclamp, sharply dissect using mayos and then suture ligate in a standard manner to get down towards the cardinal ligaments. Multiple perforating vessels were noted and hemostasis was assured with first hemostatsand then fee ties every time bleeding would be encauntered. The bladder exposure was difficult and multiple sponge sticks were used to dissect the bladder off of the servix. When Anesthesia notified the surgeons that the urine appeared slghtly blood-tinged, the bladder was retrofilled with sterile formula and methylene blue to identify if there was any intraoperative urine leak. None was noted.No blue or beige liquid was noted in the operaticve field. The bladder was then deflated and the surgery was continued. Eventually, the cardinal ligament was almost completely clamped on both sides. At this point decision was made to amputate the body of the uterus and then complete the ___ afterwards. The specimen was handed off and then suregon's attention was turned to excising the cervical tissue. Kocher clamps were placed to the 4 apices of the cervix to the anterior, posterior and lateral aspect. The cervix was elevated and again curved Heaney clamps were used to continue to cross clampon the lateral aspect of the cervix until the vagina was reached. Once the vagina was reahced , it was entered sharply using the Mayo scissors and then incision was carried all the way around the circumferential manner. The cervical stump was reexamined once it was excised and it was noted that the enitre cervical tissue was removed and only the vaginal tissue remained at this point. The vagina was identified and interrupted figure-of-eightsutures were placed for closure of the vagina. There are multiple areas that were oozing and so additional figure-of-eight sutures were placed. Pressure was held multiple times to the area, however, the oozing continued. sprey thrombin and Gelfoam were used in the normal sterile fashion, 1 was soaked in the thrombin and then placed intactto the area and then second subsequent piece of just plain gelfoam was placed above that. The area did appear heostatic. The urine continued to remain slightly blood-tinged, however, there was no active extravasation into the field. Allother pedicles were examined and were noted to be hemostatic.t this point the decision was made to remove self-retainig retractor, to remove all of the lap sponges from the abdominal and pelvic cavity which were used to tamponade some of the bleeding and hold the bowel out of the way and further surve was conducted of the pelvis. ...... and the rest of report was just the closures.