immaculatehealth
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I have gotten several very different responses in regards on how to exactly code the following OP Report.
Would someone be able to tell me definitively what CPT codes should be used with it? Thank you.
PREOPERATIVE DIAGNOSIS
Pelvic pain, ovarian dysfunction, history of ectopic pregnancy.
POSTOPERATIVE DIAGNOSIS
Pelvic pain, ovarian dysfunction, history of ectopic pregnancy plus bilateral
adnexal and lower abdominal and pelvic adhesions.
PROCEDURE
Operative laparoscopy with lysis of adhesions and tubal dye studies.
Anesthesia: General
EBL: Less than 25 cc
FINDINGS
Adhesions of the right fallopian tube from its mid segment to the mesentery of
the sigmoid colon and adhesions of the mesosalpinx to the pelvic cul-de-sac.
Left-sided adnexal adhesions were noted with adhesions of the ovarian fossa
firmly affixing the ovary to the left pelvic sidewall, and of the left
fallopian tube. Patency noted of the right fallopian tube.
OPERATIVE REPORT IN DETAIL
The patient was taken to the operating room, placed in dorsal supine position,
where adequate general endotracheal anesthesia was administered. The patient
then placed in dorsal lithotomy position with Foley catheter inserted. The
patient prepped and draped in usual sterile fashion for laparoscopy. Speculum
was put in place. Anterior lip of the cervix was grasped with a single-tooth
tenaculum and uterus was sounded and uterine cervix dilated. The RUMI uterine
manipulating device was inserted without event and attention was directed
toward the laparoscopic portion of procedure. An incision was made along the
umbilicus curvilinearly and this was extended with Kelly clamp, and Veress
needle was inserted, checked for placement and found to be accurate. The
abdomen was then insufflated to 2-3 L of CO2. Veress needle was then removed
and 10-12 mm trocar was inserted without event. Laparoscope inserted, checked
for placement, found to be appropriate. Transillumination used to identify a 5
mm suprapubic trocar site which was placed without event and careful
inspection of the upper abdomen was undergone with entirely normal findings,
and inspection of the lower pelvis undergone with above-mentioned findings.
The mini Endoshears were used with 20 watts cut and coag to carefully take
down the adhesions on both the left and right adnexa completely. At the
completion of the procedure both left and right adnexa were free of all
adhesions and adherence to adjacent tissues and methylene blue dye was
instilled through the port of the RUMI manipulating device, identifying clear
patency of the right fallopian tube. No patency demonstrated of the left
fallopian tube. Copious irrigation was then carried out and with procedure
completed pictures were taken at every stage. All instrumentation was removed
from the abdomen with the abdomen deflated of all CO2 present, and the
incision sites were injected with a Marcaine epinephrine solution and closed
with 4-0 Vicryl in a subcuticular fashion. RUMI uterine manipulating device
was removed from the vagina, and the patient was returned to the dorsal supine
position, extubated, awakened and sent to the recovery room in satisfactory
condition. Preop and postop sponge and instrument counts reported as being
correct x2.
Would someone be able to tell me definitively what CPT codes should be used with it? Thank you.
PREOPERATIVE DIAGNOSIS
Pelvic pain, ovarian dysfunction, history of ectopic pregnancy.
POSTOPERATIVE DIAGNOSIS
Pelvic pain, ovarian dysfunction, history of ectopic pregnancy plus bilateral
adnexal and lower abdominal and pelvic adhesions.
PROCEDURE
Operative laparoscopy with lysis of adhesions and tubal dye studies.
Anesthesia: General
EBL: Less than 25 cc
FINDINGS
Adhesions of the right fallopian tube from its mid segment to the mesentery of
the sigmoid colon and adhesions of the mesosalpinx to the pelvic cul-de-sac.
Left-sided adnexal adhesions were noted with adhesions of the ovarian fossa
firmly affixing the ovary to the left pelvic sidewall, and of the left
fallopian tube. Patency noted of the right fallopian tube.
OPERATIVE REPORT IN DETAIL
The patient was taken to the operating room, placed in dorsal supine position,
where adequate general endotracheal anesthesia was administered. The patient
then placed in dorsal lithotomy position with Foley catheter inserted. The
patient prepped and draped in usual sterile fashion for laparoscopy. Speculum
was put in place. Anterior lip of the cervix was grasped with a single-tooth
tenaculum and uterus was sounded and uterine cervix dilated. The RUMI uterine
manipulating device was inserted without event and attention was directed
toward the laparoscopic portion of procedure. An incision was made along the
umbilicus curvilinearly and this was extended with Kelly clamp, and Veress
needle was inserted, checked for placement and found to be accurate. The
abdomen was then insufflated to 2-3 L of CO2. Veress needle was then removed
and 10-12 mm trocar was inserted without event. Laparoscope inserted, checked
for placement, found to be appropriate. Transillumination used to identify a 5
mm suprapubic trocar site which was placed without event and careful
inspection of the upper abdomen was undergone with entirely normal findings,
and inspection of the lower pelvis undergone with above-mentioned findings.
The mini Endoshears were used with 20 watts cut and coag to carefully take
down the adhesions on both the left and right adnexa completely. At the
completion of the procedure both left and right adnexa were free of all
adhesions and adherence to adjacent tissues and methylene blue dye was
instilled through the port of the RUMI manipulating device, identifying clear
patency of the right fallopian tube. No patency demonstrated of the left
fallopian tube. Copious irrigation was then carried out and with procedure
completed pictures were taken at every stage. All instrumentation was removed
from the abdomen with the abdomen deflated of all CO2 present, and the
incision sites were injected with a Marcaine epinephrine solution and closed
with 4-0 Vicryl in a subcuticular fashion. RUMI uterine manipulating device
was removed from the vagina, and the patient was returned to the dorsal supine
position, extubated, awakened and sent to the recovery room in satisfactory
condition. Preop and postop sponge and instrument counts reported as being
correct x2.