latonya78
Contributor
I need help with a gyn/onc surgery for the following operative note:
PREOPERATIVE DIAGNOSES: Pelvic mass, abnormal CT scan, elevated CA-125.
POSTOPERATIVE DIAGNOSIS: Serous epithelial tumor of the ovary, borderline low malignant potential tumor, possible invasion.
PROCEDURE: Exploratory laparotomy, right ureterolysis, total abdominal hysterectomy, left salpingo-oophorectomy, left and right pelvic lymph node dissection, left paraaortic lymph node dissection, right ovarian cystectomy, right salpingectomy, right ovarian oophoropexy, omentectomy, appendectomy, staging with peritoneal biopsies.
INDICATIONS: A 31-year-old female, patient of Dr. McFarland, who was taken to the operating room for diagnostic laparoscopy, unilateral salpingo-oophorectomy, possible exploratory laparotomy, hysterectomy staging if malignancy was discovered.
DESCRIPTION OF PROCEDURE: The patient underwent diagnostic laparoscopy. See his dictation for details with findings of left ovarian mass involved with papillary structure approximately 6-8 centimeters in diameter consistent with ovarian neoplasm borderline tumor versus a malignancy. The patient also had evidence of metastatic implants involving the pelvis, uterine serosa.
A low vertical skin incision was made from the pubic symphysis to approximately 3 fingerbreadths above the umbilicus. This was carried down to fascia. Fascia was nicked in the midline, extended superiorly and inferiorly. The peritoneum was entered sharply. Exploration of the abdominal pelvic contents reflected no evidence of disease above the level of the pelvic brim. However, pelvic, dilated right ureter, dilated right fallopian tube, obliterated cul-de-sac and what appeared to be tumor implant on the posterior surface of the uterus. Tumor involved the left ovary and fallopian tube was appreciated. A self-retaining Bookwalter was placed. Bowel was packed out of the field. Attention was paid to the left round ligament which was isolated with surgical instrument and sacrificed with Hem-o-lock clip x2. The retroperitoneum was developed and the incision was carried along the peritoneum to the level of the pelvic brim. The left paravesical and pararectal spaces were developed. The left ureter was identified at the level of the medial leaf of the broad ligament. Vessel loop was placed across the left ureter. Next, the uterine artery was isolated at the bifurcation with the hypogastric artery and sacrificed with the stapler using a vascular load. Next, the left ovarian artery and vein were isolated at the level above the pelvic brim, clipped with Hem-o-lock clip x3 and transected. Next, the medial leaf of the broad ligament was incised down to the level of the uterosacral ligament and peritoneum was mobilized medially. Remaining attachments of the mass to the rectosigmoid and posterior aspect of the uterus were dissected free. A stapler was used to transect the uteroovarian ligament and the base of the fallopian tube and specimen was passed off for frozen section analysis.
Frozen section analysis reflected at least a borderline tumor with concerns for invasion. The procedure continued. The omentectomy was performed in the standard fashion where the short gastric arteries were isolated, clipped with Hem-O-lock clip and transected. The attachments of the omentum to the transverse colon pedicles were isolated, clipped with the Hem-O-lock clip and transected and the omentum was passed off the field. Pericolic gutters were inspected, sampled. The retroperitoneum was mobilized and the left and right pericolic gutter biopsies were performed approximately 3-2 centimeters in diameter. The appendix was isolated, grasped with Babcock clamp. The mesoappendix was clamped with a short hemostat clamp x2, cut and secured with 2-0 Vicryl on SH needle. The base of the appendix was transected with a stapler. The bowel was run from the ileocecal junction to the ligament of Treitz. There was no evidence of mesentery involvement or serosal involvement. In addition, the transverse and ascending and descending colon were also free of disease. Palpation of the periaortic nodes was unremarkable. Secondary to involvement of the serosa of the uterus, the hysterectomy was performed whereas the Kelly clamps were placed around the cornu of the uterus. The vesicovaginal fold was taken down sharply to the level of the anterior vagina. The right round ligament was in a similar manner sacrificed with Hem-o-lock clip. The retroperitoneum was developed. In a similar manner the peritoneum overlying the right psoas muscle was extended to the pelvic brim. The ureter was identified in the medial leaf. A vessel loop was placed across the ureter and the ureter was dissected down to the cardinal ligament. The uterine artery was isolated at its hypogastric region branching from the hypogastric and transected with a vessel loop. The paravesical and perirectal spaces had been developed. The medial leaf of the broad ligament was incised down to the level of uterosacral ligament. The right uterosacral ligament was inflamed and thickened and appeared be involved with the tumor process. A modified radical hysterectomy on the right side was performed whereas the ureter was dissected all the way down to the bladder and unroofed and cardinal ligament was clamped with MD Anderson clamp midway at its insertion site x2 and transected and secured. The pedicle was secured with 2-0 Vicryl on straight Haney clamps for the cardinal and uterosacral ligaments were then used and these pedicles were cut and secured with 2-0 Vicryl on SH needle. The anterior vagina was incised with the electrosurgical instrument. Curved Haney clamps were placed in this defect and the specimen portion of the vagina, cervix, parametria, right parametria, uterus was delivered off the field. The cuff was closed with 0 Vicryl with interrupted figure-of-eight stitches. Good hemostasis was noted throughout. Dr. McFarland had spoken to the patient's family during the procedure regarding findings and planned surgical procedure. The right ovary was carefully inspected, appeared to be enlarged and involved with a corpus luteum cyst. The right fallopian tube was sacrificed in the standard fashion and passed off the field. Good hemostasis was noted. This appeared to have hydrosalpinx. No tumor involvement. The right over ovary was otherwise unremarkable in appearance. Right oophoropexy was performed where the right ovary was attached to the tinea of the right psoas muscle as well as the peritoneum and this was secured with 0 Vicryl figure-of-eight sutures. Careful inspection of all the abdominal pelvic contents reflected no evidence of disease. The left and right pelvic lymph node dissection was performed whereas the peritoneum overlying the greater vessels was incised. The retroperitoneum was developed. The lymph node bundle in the obturator spaces bilaterally superior to the obturator nerve and inferior to the great vessels from the level of the circumflex iliac vein to the bifurcation of the hypogastric was all dissected free and passed off the field. There was scant tissue overlying the external iliac artery and vein. A left periaortic lymph node dissection was performed whereas lymphatic tissue at the level of the bifurcation of the aorta was dissected free and a sample was sent off. These lymph nodes, though, had an unremarkable appearance. All instruments were removed from the patient's abdomen. Sponge count was correct x2. The fascia was closed with #1 PDS. Skin was stapled. Dressing was applied.
The CPT code that was submitted is 59854. Should I use this code with a modifier 52 since the right ovary was not removed and do I need to submit a cpt code for right ovarian oophorpexy.
PREOPERATIVE DIAGNOSES: Pelvic mass, abnormal CT scan, elevated CA-125.
POSTOPERATIVE DIAGNOSIS: Serous epithelial tumor of the ovary, borderline low malignant potential tumor, possible invasion.
PROCEDURE: Exploratory laparotomy, right ureterolysis, total abdominal hysterectomy, left salpingo-oophorectomy, left and right pelvic lymph node dissection, left paraaortic lymph node dissection, right ovarian cystectomy, right salpingectomy, right ovarian oophoropexy, omentectomy, appendectomy, staging with peritoneal biopsies.
INDICATIONS: A 31-year-old female, patient of Dr. McFarland, who was taken to the operating room for diagnostic laparoscopy, unilateral salpingo-oophorectomy, possible exploratory laparotomy, hysterectomy staging if malignancy was discovered.
DESCRIPTION OF PROCEDURE: The patient underwent diagnostic laparoscopy. See his dictation for details with findings of left ovarian mass involved with papillary structure approximately 6-8 centimeters in diameter consistent with ovarian neoplasm borderline tumor versus a malignancy. The patient also had evidence of metastatic implants involving the pelvis, uterine serosa.
A low vertical skin incision was made from the pubic symphysis to approximately 3 fingerbreadths above the umbilicus. This was carried down to fascia. Fascia was nicked in the midline, extended superiorly and inferiorly. The peritoneum was entered sharply. Exploration of the abdominal pelvic contents reflected no evidence of disease above the level of the pelvic brim. However, pelvic, dilated right ureter, dilated right fallopian tube, obliterated cul-de-sac and what appeared to be tumor implant on the posterior surface of the uterus. Tumor involved the left ovary and fallopian tube was appreciated. A self-retaining Bookwalter was placed. Bowel was packed out of the field. Attention was paid to the left round ligament which was isolated with surgical instrument and sacrificed with Hem-o-lock clip x2. The retroperitoneum was developed and the incision was carried along the peritoneum to the level of the pelvic brim. The left paravesical and pararectal spaces were developed. The left ureter was identified at the level of the medial leaf of the broad ligament. Vessel loop was placed across the left ureter. Next, the uterine artery was isolated at the bifurcation with the hypogastric artery and sacrificed with the stapler using a vascular load. Next, the left ovarian artery and vein were isolated at the level above the pelvic brim, clipped with Hem-o-lock clip x3 and transected. Next, the medial leaf of the broad ligament was incised down to the level of the uterosacral ligament and peritoneum was mobilized medially. Remaining attachments of the mass to the rectosigmoid and posterior aspect of the uterus were dissected free. A stapler was used to transect the uteroovarian ligament and the base of the fallopian tube and specimen was passed off for frozen section analysis.
Frozen section analysis reflected at least a borderline tumor with concerns for invasion. The procedure continued. The omentectomy was performed in the standard fashion where the short gastric arteries were isolated, clipped with Hem-O-lock clip and transected. The attachments of the omentum to the transverse colon pedicles were isolated, clipped with the Hem-O-lock clip and transected and the omentum was passed off the field. Pericolic gutters were inspected, sampled. The retroperitoneum was mobilized and the left and right pericolic gutter biopsies were performed approximately 3-2 centimeters in diameter. The appendix was isolated, grasped with Babcock clamp. The mesoappendix was clamped with a short hemostat clamp x2, cut and secured with 2-0 Vicryl on SH needle. The base of the appendix was transected with a stapler. The bowel was run from the ileocecal junction to the ligament of Treitz. There was no evidence of mesentery involvement or serosal involvement. In addition, the transverse and ascending and descending colon were also free of disease. Palpation of the periaortic nodes was unremarkable. Secondary to involvement of the serosa of the uterus, the hysterectomy was performed whereas the Kelly clamps were placed around the cornu of the uterus. The vesicovaginal fold was taken down sharply to the level of the anterior vagina. The right round ligament was in a similar manner sacrificed with Hem-o-lock clip. The retroperitoneum was developed. In a similar manner the peritoneum overlying the right psoas muscle was extended to the pelvic brim. The ureter was identified in the medial leaf. A vessel loop was placed across the ureter and the ureter was dissected down to the cardinal ligament. The uterine artery was isolated at its hypogastric region branching from the hypogastric and transected with a vessel loop. The paravesical and perirectal spaces had been developed. The medial leaf of the broad ligament was incised down to the level of uterosacral ligament. The right uterosacral ligament was inflamed and thickened and appeared be involved with the tumor process. A modified radical hysterectomy on the right side was performed whereas the ureter was dissected all the way down to the bladder and unroofed and cardinal ligament was clamped with MD Anderson clamp midway at its insertion site x2 and transected and secured. The pedicle was secured with 2-0 Vicryl on straight Haney clamps for the cardinal and uterosacral ligaments were then used and these pedicles were cut and secured with 2-0 Vicryl on SH needle. The anterior vagina was incised with the electrosurgical instrument. Curved Haney clamps were placed in this defect and the specimen portion of the vagina, cervix, parametria, right parametria, uterus was delivered off the field. The cuff was closed with 0 Vicryl with interrupted figure-of-eight stitches. Good hemostasis was noted throughout. Dr. McFarland had spoken to the patient's family during the procedure regarding findings and planned surgical procedure. The right ovary was carefully inspected, appeared to be enlarged and involved with a corpus luteum cyst. The right fallopian tube was sacrificed in the standard fashion and passed off the field. Good hemostasis was noted. This appeared to have hydrosalpinx. No tumor involvement. The right over ovary was otherwise unremarkable in appearance. Right oophoropexy was performed where the right ovary was attached to the tinea of the right psoas muscle as well as the peritoneum and this was secured with 0 Vicryl figure-of-eight sutures. Careful inspection of all the abdominal pelvic contents reflected no evidence of disease. The left and right pelvic lymph node dissection was performed whereas the peritoneum overlying the greater vessels was incised. The retroperitoneum was developed. The lymph node bundle in the obturator spaces bilaterally superior to the obturator nerve and inferior to the great vessels from the level of the circumflex iliac vein to the bifurcation of the hypogastric was all dissected free and passed off the field. There was scant tissue overlying the external iliac artery and vein. A left periaortic lymph node dissection was performed whereas lymphatic tissue at the level of the bifurcation of the aorta was dissected free and a sample was sent off. These lymph nodes, though, had an unremarkable appearance. All instruments were removed from the patient's abdomen. Sponge count was correct x2. The fascia was closed with #1 PDS. Skin was stapled. Dressing was applied.
The CPT code that was submitted is 59854. Should I use this code with a modifier 52 since the right ovary was not removed and do I need to submit a cpt code for right ovarian oophorpexy.
my company also has us signed up w/ optum encoder which is an awesome program but a little expensive.