Good morning!
I am looking for some assistance in how to bill this procedure out correctly and diagnosis correctly. The office has two differing opinions on how this should be billed. I have included the OP report below if someone can help me out.
On the procedure coding I am leaning towards CPT codes 58558 with Dx N93.8 and R10.2 and 58662 with modifier 51 with dx for the removal of the Filshie Clip T83.428A N80.C4 N80.3C2
Thank you in advance!
Pre-op Diagnosis
* Other specified abnormal uterine and vaginal bleeding [N93.8]
* Pelvic and perineal pain [R10.2]
Postop Diagnosis - Pelvic pain
1. AUB
2. Endometriosis
3. Displaced Filshie clip
Findings: Laparoscopy: endometriosis lesions approx. 2mm in size scattered on sidewall near left adnexa, anterior peritoneum adjacent to bladder, uterosacral ligaments, a few on the omentum; hysteroscopy: uterine cavity-thickened appearing endometrium; difficult to visualize tubal ostia, no fibroids or polyps noted
Procedure Details:
The patient was taken to the operating room with IV fluids running and placed in a dorsal supine position. General anesthesia was obtained and found to be adequate. She was repositioned into a dorsal lithotomy using Allen stirrups. Arms tucked to the side. She was prepped and draped abdominally and vaginally in the normal routine sterile fashion. A timeout was performed prior to the start of procedure. Attention was then turned to her pelvis where a foley catheter was placed into her bladder to evacuate urine intraoperatively. In addition, a diagnostic V-Care was placed into the vagina to be used to aid in manipulation of the uterus.
Attention was then turned to the patient's abdomen. The infraumbilical skin fold was anesthetized with 2 mL of 0.25 percent Marcaine. An infraumbilical vertical, 5 mm skin incision was made with the scalpel. A Veress needle was used to enter the abdomen, correct placement confirmed with saline drop test and opening pressure of 5 mmHg. Once Intra-abdominal insufflation was noted to be adequate, the Veress was removed. A direct technique using an visible trocar with the 5mm laparoscope, was performed to successfully to enter into the abdomen. A survey of the abdominal contents noted to be normal, stable, without injury. Filshie clip was noted on the omentum in the upper left abdomen. Normal appearing liver. The patient was placed in Trendelenburg. At this time, the RLQ region was transilluminated, and an accessory trocar site was mapped out. The skin was first anesthetized with 2 mL of 0.25 percent Marcaine. Under direct visualization with the laparoscope, an 5 mm skin incision was made with the scalpel and the 5 mm trocar was placed under direct visualization with the laparoscope successfully. Same procedure was performed for a LLQ port entry and an 8mm trocar was placed. Endometriosis lesions noted: approximately 2mm in size scattered on sidewall near left adnexa, anterior peritoneum adjacent to bladder, uterosacral ligaments, a few on the omentum. Posterior fibroid noted on uterus, otherwise uterus mobile. Adhesive disease noted left adnexa around left ovary. Edge of other Filshie clip noted in the adhesions near the left ovary.
The laparoscopic grasper was used to grasp the Filshie clip from the LUQ omentum and removed through the 8mm trocar. The scalpel cautery was used to fulgurate the endometriosis lesions. Attention was made to the pelvic sidewall to stay away from the ureter. Adhesions were taken down around the left ovary and pelvic sidewall. A cyst was removed from the anterior abdominal wall and removed. Pictures were taken. Suction irrigation was used. Everything appeared hemostatic and stable; therefore, all instruments were removed from the abdomen. The camera was removed, and the gas was stopped and then evacuated from the trocar port sites. Once all gas appeared removed, the trocars were removed successfully. The abdomen was cleaned with warm sterile saline. The incision sites were dried, closed with 4-0 Monocryl subcutaneously, then Dermabond was applied over the skin incision sites.
The diagnostic V-Care was removed from the vagina and foley catheter removed from the bladder. A weighted speculum was placed into the posterior aspect of the vagina, and the anterior lip of the cervix was grasped with a tenaculum and drawn forward. The uterus sounded to 10 cm. The cervix was then gently serially dilated using Pratt dilators to accommodate the Symphion hysteroscope. The hysteroscope was then advanced into the uterine cavity, and the cavity and endometrial lining were surveyed with the above noted findings. The hysteroscope was then removed. The small sharp curet was then advanced into the uterine cavity and the endometrium was curetted to a uniform gritty consistency. The specimens of endometrium were sent to Pathology for examination.
Needle, sponge and instrument counts were correct times two. The patient tolerated this procedure well and was transferred to the Post Anesthesia Care Unit in stable condition.
I am looking for some assistance in how to bill this procedure out correctly and diagnosis correctly. The office has two differing opinions on how this should be billed. I have included the OP report below if someone can help me out.
On the procedure coding I am leaning towards CPT codes 58558 with Dx N93.8 and R10.2 and 58662 with modifier 51 with dx for the removal of the Filshie Clip T83.428A N80.C4 N80.3C2
Thank you in advance!
Pre-op Diagnosis
* Other specified abnormal uterine and vaginal bleeding [N93.8]
* Pelvic and perineal pain [R10.2]
Postop Diagnosis - Pelvic pain
1. AUB
2. Endometriosis
3. Displaced Filshie clip
Findings: Laparoscopy: endometriosis lesions approx. 2mm in size scattered on sidewall near left adnexa, anterior peritoneum adjacent to bladder, uterosacral ligaments, a few on the omentum; hysteroscopy: uterine cavity-thickened appearing endometrium; difficult to visualize tubal ostia, no fibroids or polyps noted
Procedure Details:
The patient was taken to the operating room with IV fluids running and placed in a dorsal supine position. General anesthesia was obtained and found to be adequate. She was repositioned into a dorsal lithotomy using Allen stirrups. Arms tucked to the side. She was prepped and draped abdominally and vaginally in the normal routine sterile fashion. A timeout was performed prior to the start of procedure. Attention was then turned to her pelvis where a foley catheter was placed into her bladder to evacuate urine intraoperatively. In addition, a diagnostic V-Care was placed into the vagina to be used to aid in manipulation of the uterus.
Attention was then turned to the patient's abdomen. The infraumbilical skin fold was anesthetized with 2 mL of 0.25 percent Marcaine. An infraumbilical vertical, 5 mm skin incision was made with the scalpel. A Veress needle was used to enter the abdomen, correct placement confirmed with saline drop test and opening pressure of 5 mmHg. Once Intra-abdominal insufflation was noted to be adequate, the Veress was removed. A direct technique using an visible trocar with the 5mm laparoscope, was performed to successfully to enter into the abdomen. A survey of the abdominal contents noted to be normal, stable, without injury. Filshie clip was noted on the omentum in the upper left abdomen. Normal appearing liver. The patient was placed in Trendelenburg. At this time, the RLQ region was transilluminated, and an accessory trocar site was mapped out. The skin was first anesthetized with 2 mL of 0.25 percent Marcaine. Under direct visualization with the laparoscope, an 5 mm skin incision was made with the scalpel and the 5 mm trocar was placed under direct visualization with the laparoscope successfully. Same procedure was performed for a LLQ port entry and an 8mm trocar was placed. Endometriosis lesions noted: approximately 2mm in size scattered on sidewall near left adnexa, anterior peritoneum adjacent to bladder, uterosacral ligaments, a few on the omentum. Posterior fibroid noted on uterus, otherwise uterus mobile. Adhesive disease noted left adnexa around left ovary. Edge of other Filshie clip noted in the adhesions near the left ovary.
The laparoscopic grasper was used to grasp the Filshie clip from the LUQ omentum and removed through the 8mm trocar. The scalpel cautery was used to fulgurate the endometriosis lesions. Attention was made to the pelvic sidewall to stay away from the ureter. Adhesions were taken down around the left ovary and pelvic sidewall. A cyst was removed from the anterior abdominal wall and removed. Pictures were taken. Suction irrigation was used. Everything appeared hemostatic and stable; therefore, all instruments were removed from the abdomen. The camera was removed, and the gas was stopped and then evacuated from the trocar port sites. Once all gas appeared removed, the trocars were removed successfully. The abdomen was cleaned with warm sterile saline. The incision sites were dried, closed with 4-0 Monocryl subcutaneously, then Dermabond was applied over the skin incision sites.
The diagnostic V-Care was removed from the vagina and foley catheter removed from the bladder. A weighted speculum was placed into the posterior aspect of the vagina, and the anterior lip of the cervix was grasped with a tenaculum and drawn forward. The uterus sounded to 10 cm. The cervix was then gently serially dilated using Pratt dilators to accommodate the Symphion hysteroscope. The hysteroscope was then advanced into the uterine cavity, and the cavity and endometrial lining were surveyed with the above noted findings. The hysteroscope was then removed. The small sharp curet was then advanced into the uterine cavity and the endometrium was curetted to a uniform gritty consistency. The specimens of endometrium were sent to Pathology for examination.
Needle, sponge and instrument counts were correct times two. The patient tolerated this procedure well and was transferred to the Post Anesthesia Care Unit in stable condition.