My physician would like to bill for temporary stent placement while he performs other procedures. I know that 52005 is billable but is it complaint to bill this and everything else?
After signing the informed consent, the patient was transferred to OR
#8 at Ahuja Medical Center. Under general anesthesia, prepped and
draped in dorsal supine position. Both access to the abdomen and
vagina. We started the procedure with cystoscopy for evaluation of
overactive bladder and also as well, we did 5-French stent into the
right and 5-French stent into the left ureter to help with
identification of the ureter during the procedure given the expected
difficulty of the case. The bladder appeared with no diagnostic
abnormality. No masses, no lesions, and no other issues. Urethra
appeared with no diagnostic abnormality. After completing this part,
we did dilate the cervix up to 26 and we inserted a medium VCare into
the uterus to help with manipulation of the uterus during the
procedure.
Then, we directed our attention to the abdomen. We did open entry
through the umbilicus with 1 cm incision. We did then had 5 mm
ports, 2 on the right and 2 on the left, and then we started the
procedure by inspection that confirmed the difficulty of the case and
the adhesions between the anterior wall of the uterus and the
anterior abdominal wall that extend and thick adhesions all over in
the presence of fibroids. Also the tubes were attached to the
anterior abdominal wall as well. We started by doing a bilateral
salpingectomy starting by dissecting the tubes off the anterior
abdominal wall and then we clamped the uterine end of the tube and
then using ligature was separated with careful dissection to avoid
any bleeding. Both tubes were sent for pathological evaluation.
Next, we directed our attention to the approach for the hysterectomy.
We started by opening the broad ligament by identifying the round
ligament. There were massive adhesions on top of the round ligament
that had secured it. I identified them on the right side and opened
it. The ureter was identified, and then we started dissecting
posteriorly with the posterior leaf of the peritoneum to make sure
that we are clear of the ureter on the back side. We did the same
thing on the left side. This helped opening the broad ligament,
identifying the ureter, and skeletonizing the posterior leaf and the
uterine arteries on that side. Then, we did do the tubo-ovarian
ligament on the right and tubo-ovarian ligament on the left to
separate the uterus from both ovaries, which we decided to keep per
my discussion with the patient. Then anteriorly given the
implication of the anterior wall of the uterus and the anterior
abdominal wall, we did dissect open the anterior peritoneum and we
started dissecting the uterus off the anterior abdominal wall. Then,
we entered into the space of Retzius and we dissected the bladder
along with the uterus from the anterior abdominal wall. After that,
we expanded the dissection laterally up to the medial umbilical
ligament and then we further tried to separate the uterus from the
bladder with sharp dissection using scissors in the midline down
towards the cervix and the vaginal ring of the VCare. This
dissection was extensive and took more than 60 minutes because of the
prior adhesions that were known before the procedure. Careful
dissection was done. No injury to the bladder was noted and we did
cystoscopy to confirm. The ureteric stents were essential for
identification of the ureter to make sure that the surgery was safe.
That is why, we are billing for it. We are billing for a difficult
hysterectomy. After dissecting the bladder off the cervix and
anterior vaginal wall, we directed our attention to further
skeletonizing the uterine artery on the right and left and then we
ligated and cut the uterine artery on the right and ligated and cut
the uterine artery on the left. Prior to that, we did use some
vasopressin to minimize the bleeding from the dissection of the
anterior abdominal wall from the anterior uterine wall.
After completing the devascularization of the uterus, we did enter
the vagina anteriorly and we opened the cuff anteriorly and
posteriorly. Hemostasis was ascertained, and the uterus was
delivered vaginally.
After completing that, I identified the uterosacral ligaments on the
right and left and we did support the apex by uterosacral colpopexy
utilizing Mayo modified McCall culdoplasty starting on the posterior
vaginal wall into the uterosacral ligament crossing across the
peritoneum on top of the sigmoid into the left uterosacral ligament
into the right uterosacral ligament and out through the posterior
vaginal wall. We did 3 sutures, 2 Vicryl-0, and 1 Maxon. Then we
closed the peritoneum using Vicryl-0 suture starting in the
uterosacral ligament on the right including the peritoneum on top of
the bladder, then closing the cul-de-sac, and then including the
peritoneum on the bladder and uterosacral on the left side and then I
exteriorized those 2 ends of the sutures out through the vagina. I
serially tied all those sutures and did cystoscopy in between to make
sure that we do not have any injury to the ureter or bladder during
tying these sutures. This resulted in excellent support of the apex.
The patient tolerated that part of the procedure very well. After
that, we did another cystoscopy. Stents were removed. Then, we
directed our attention to the abdomen. The umbilical incision was
closed. The fascia was closed utilizing Vicryl sutures, and the skin
was closed in all 5 incisions. The patient tolerated the procedure
very well, transferred to the PACU in stable condition. This was a
difficult procedure and billing for a difficult hysterectomy and
billing for the stents that were utilized to visualize the ureters
all the time during the procedure.
After signing the informed consent, the patient was transferred to OR
#8 at Ahuja Medical Center. Under general anesthesia, prepped and
draped in dorsal supine position. Both access to the abdomen and
vagina. We started the procedure with cystoscopy for evaluation of
overactive bladder and also as well, we did 5-French stent into the
right and 5-French stent into the left ureter to help with
identification of the ureter during the procedure given the expected
difficulty of the case. The bladder appeared with no diagnostic
abnormality. No masses, no lesions, and no other issues. Urethra
appeared with no diagnostic abnormality. After completing this part,
we did dilate the cervix up to 26 and we inserted a medium VCare into
the uterus to help with manipulation of the uterus during the
procedure.
Then, we directed our attention to the abdomen. We did open entry
through the umbilicus with 1 cm incision. We did then had 5 mm
ports, 2 on the right and 2 on the left, and then we started the
procedure by inspection that confirmed the difficulty of the case and
the adhesions between the anterior wall of the uterus and the
anterior abdominal wall that extend and thick adhesions all over in
the presence of fibroids. Also the tubes were attached to the
anterior abdominal wall as well. We started by doing a bilateral
salpingectomy starting by dissecting the tubes off the anterior
abdominal wall and then we clamped the uterine end of the tube and
then using ligature was separated with careful dissection to avoid
any bleeding. Both tubes were sent for pathological evaluation.
Next, we directed our attention to the approach for the hysterectomy.
We started by opening the broad ligament by identifying the round
ligament. There were massive adhesions on top of the round ligament
that had secured it. I identified them on the right side and opened
it. The ureter was identified, and then we started dissecting
posteriorly with the posterior leaf of the peritoneum to make sure
that we are clear of the ureter on the back side. We did the same
thing on the left side. This helped opening the broad ligament,
identifying the ureter, and skeletonizing the posterior leaf and the
uterine arteries on that side. Then, we did do the tubo-ovarian
ligament on the right and tubo-ovarian ligament on the left to
separate the uterus from both ovaries, which we decided to keep per
my discussion with the patient. Then anteriorly given the
implication of the anterior wall of the uterus and the anterior
abdominal wall, we did dissect open the anterior peritoneum and we
started dissecting the uterus off the anterior abdominal wall. Then,
we entered into the space of Retzius and we dissected the bladder
along with the uterus from the anterior abdominal wall. After that,
we expanded the dissection laterally up to the medial umbilical
ligament and then we further tried to separate the uterus from the
bladder with sharp dissection using scissors in the midline down
towards the cervix and the vaginal ring of the VCare. This
dissection was extensive and took more than 60 minutes because of the
prior adhesions that were known before the procedure. Careful
dissection was done. No injury to the bladder was noted and we did
cystoscopy to confirm. The ureteric stents were essential for
identification of the ureter to make sure that the surgery was safe.
That is why, we are billing for it. We are billing for a difficult
hysterectomy. After dissecting the bladder off the cervix and
anterior vaginal wall, we directed our attention to further
skeletonizing the uterine artery on the right and left and then we
ligated and cut the uterine artery on the right and ligated and cut
the uterine artery on the left. Prior to that, we did use some
vasopressin to minimize the bleeding from the dissection of the
anterior abdominal wall from the anterior uterine wall.
After completing the devascularization of the uterus, we did enter
the vagina anteriorly and we opened the cuff anteriorly and
posteriorly. Hemostasis was ascertained, and the uterus was
delivered vaginally.
After completing that, I identified the uterosacral ligaments on the
right and left and we did support the apex by uterosacral colpopexy
utilizing Mayo modified McCall culdoplasty starting on the posterior
vaginal wall into the uterosacral ligament crossing across the
peritoneum on top of the sigmoid into the left uterosacral ligament
into the right uterosacral ligament and out through the posterior
vaginal wall. We did 3 sutures, 2 Vicryl-0, and 1 Maxon. Then we
closed the peritoneum using Vicryl-0 suture starting in the
uterosacral ligament on the right including the peritoneum on top of
the bladder, then closing the cul-de-sac, and then including the
peritoneum on the bladder and uterosacral on the left side and then I
exteriorized those 2 ends of the sutures out through the vagina. I
serially tied all those sutures and did cystoscopy in between to make
sure that we do not have any injury to the ureter or bladder during
tying these sutures. This resulted in excellent support of the apex.
The patient tolerated that part of the procedure very well. After
that, we did another cystoscopy. Stents were removed. Then, we
directed our attention to the abdomen. The umbilical incision was
closed. The fascia was closed utilizing Vicryl sutures, and the skin
was closed in all 5 incisions. The patient tolerated the procedure
very well, transferred to the PACU in stable condition. This was a
difficult procedure and billing for a difficult hysterectomy and
billing for the stents that were utilized to visualize the ureters
all the time during the procedure.