Hello,
We were wondering what CPT you would assign, with the following description of procedure.
DESCRIPTION OF PROCEDURE:
Dr. Gyn attention was then turned to the patient's abdomen and a 5 mm infraumbilical incision was made with a scalpel. The 5-mm trocar and scope were inserted in this incision under direct visualization and without complication. Once intraperitoneal placement was confirmed, the abdomen was observed with the findings noted above. At that time, it was noted that the tip of the trocar had lacerated what appeared to be the pelvic mass with some slight oozing from that area. At that time with observation of the pelvis, the uterus and the other pelvic structures were completely encased with the omentum and large bowel and so a general surgery consult was done. General surgery did come in. The left lower quadrant 5-mm incision had been made and the trocar had been inserted into that incision under direct visualization without complication. At that time, Dr. Gen Sur did arrive to the OR and observed the findings noted above. He did in fact scrub in, please see his dictated operative report for details for his part of procedure. Dr. Gen Sur, at that time, was able to free some of the omentum from the uterus and from this pelvic mass. It was thought that in order to discover what the masses were that were seen on ultrasound we would need to go ahead and open the patient if we felt it could not be safely continued laparoscopically due to bleeding and possible injury to the bowel. So the trocars were removed. A Pfannenstiel skin incision was then made through the patient's old C-section incision. This was carried down to the fascia sharply and bluntly. The fascia was incised in the midline and this was extended bilaterally with the Mayo scissors. The superior aspect of this incision was grasped with Kocher clamps, tented up and the rectus muscles dissected off sharply and bluntly. The same was done inferiorly. The rectus muscles were divided in the midline, the peritoneum was identified. It was entered bluntly and this was extended superiorly and inferiorly. The O'Connor-O'Sullivan retractor was then placed and the bowel was packed away with moist laparotomy sponges where it could be. Dr. Gen Sur continued to take down the omentum and the bowel. The area where the tip of the trocar had caused the superficial laceration was against some of the encased scar tissue but not into any particular organ and into the mass and was emostatic at that time, so doing some blunt and sharp dissection of this pelvic mass it was superior to the uterus, it was punctured and copious pus was seen coming out. Once the plane could be seen between the mass and the uterus, the LigaSure was used to separate the mass from the uterus and from the surrounding scar tissue essentially _____ omentum had been dissected off and then this structure was removed and sent for frozen. The pelvis was copiously irrigated. There was some oozing noted against the raw surface of the fundus of the uterus also and as there had been some blunt dissection down on the patient's right to see if the ovary could be identified which it was. There was some oozing again from the breaking down of the scar tissue in the blunt dissection. The pelvis was copiously irrigated and then hemostatic powder was used in the oozing areas at the fundus in the pelvis where the base of the mass was and then also on that left side. At that time, Dr. Gen Sur did place a JP drain and pulled it through that the lower left quadrant trocar site and that was placed into the patient's right lower quadrant. Once hemostasis was assured, all sponges and instruments and the retractor were removed. The fascia was then reapproximated with 0 PDS in a running fashion. The subcuticular adipose tissue was brought together with a running stitch of plain and the skin closed in a subcuticular fashion with 4-0 Monocryl. The sponge stick was removed from the vagina. The infraumbilical incision was closed in a subcuticular fashion with 4-0 Monocryl and the patient was awakened and taken to the recovery room in stable condition with the plan to start IV antibiotics for likely tubo-ovarian abscess.
Final Pathologic Diagnosis:
PELVIS, EXCISION:
- Tuboovarian abscess.
- Negative for malignancy.
The specimen is 98 gm, 9.2 x 7.0 x 3.4 cm.
We came up with the following CPT: 49204 ICD-10:N70.93, thinking the lysis of adhesions and draining is included within the excision code. Your input is greatly appreciated.
We were wondering what CPT you would assign, with the following description of procedure.
DESCRIPTION OF PROCEDURE:
Dr. Gyn attention was then turned to the patient's abdomen and a 5 mm infraumbilical incision was made with a scalpel. The 5-mm trocar and scope were inserted in this incision under direct visualization and without complication. Once intraperitoneal placement was confirmed, the abdomen was observed with the findings noted above. At that time, it was noted that the tip of the trocar had lacerated what appeared to be the pelvic mass with some slight oozing from that area. At that time with observation of the pelvis, the uterus and the other pelvic structures were completely encased with the omentum and large bowel and so a general surgery consult was done. General surgery did come in. The left lower quadrant 5-mm incision had been made and the trocar had been inserted into that incision under direct visualization without complication. At that time, Dr. Gen Sur did arrive to the OR and observed the findings noted above. He did in fact scrub in, please see his dictated operative report for details for his part of procedure. Dr. Gen Sur, at that time, was able to free some of the omentum from the uterus and from this pelvic mass. It was thought that in order to discover what the masses were that were seen on ultrasound we would need to go ahead and open the patient if we felt it could not be safely continued laparoscopically due to bleeding and possible injury to the bowel. So the trocars were removed. A Pfannenstiel skin incision was then made through the patient's old C-section incision. This was carried down to the fascia sharply and bluntly. The fascia was incised in the midline and this was extended bilaterally with the Mayo scissors. The superior aspect of this incision was grasped with Kocher clamps, tented up and the rectus muscles dissected off sharply and bluntly. The same was done inferiorly. The rectus muscles were divided in the midline, the peritoneum was identified. It was entered bluntly and this was extended superiorly and inferiorly. The O'Connor-O'Sullivan retractor was then placed and the bowel was packed away with moist laparotomy sponges where it could be. Dr. Gen Sur continued to take down the omentum and the bowel. The area where the tip of the trocar had caused the superficial laceration was against some of the encased scar tissue but not into any particular organ and into the mass and was emostatic at that time, so doing some blunt and sharp dissection of this pelvic mass it was superior to the uterus, it was punctured and copious pus was seen coming out. Once the plane could be seen between the mass and the uterus, the LigaSure was used to separate the mass from the uterus and from the surrounding scar tissue essentially _____ omentum had been dissected off and then this structure was removed and sent for frozen. The pelvis was copiously irrigated. There was some oozing noted against the raw surface of the fundus of the uterus also and as there had been some blunt dissection down on the patient's right to see if the ovary could be identified which it was. There was some oozing again from the breaking down of the scar tissue in the blunt dissection. The pelvis was copiously irrigated and then hemostatic powder was used in the oozing areas at the fundus in the pelvis where the base of the mass was and then also on that left side. At that time, Dr. Gen Sur did place a JP drain and pulled it through that the lower left quadrant trocar site and that was placed into the patient's right lower quadrant. Once hemostasis was assured, all sponges and instruments and the retractor were removed. The fascia was then reapproximated with 0 PDS in a running fashion. The subcuticular adipose tissue was brought together with a running stitch of plain and the skin closed in a subcuticular fashion with 4-0 Monocryl. The sponge stick was removed from the vagina. The infraumbilical incision was closed in a subcuticular fashion with 4-0 Monocryl and the patient was awakened and taken to the recovery room in stable condition with the plan to start IV antibiotics for likely tubo-ovarian abscess.
Final Pathologic Diagnosis:
PELVIS, EXCISION:
- Tuboovarian abscess.
- Negative for malignancy.
The specimen is 98 gm, 9.2 x 7.0 x 3.4 cm.
We came up with the following CPT: 49204 ICD-10:N70.93, thinking the lysis of adhesions and draining is included within the excision code. Your input is greatly appreciated.