NVobgynCoder
Contributor
I have an interesting operative note that I'm looking at and trying to figure out the best way to code this. The patient came to our office to discuss sterilization with the doctor and stated that she currently has an IUD. Pt decided to proceed with bi-lateral tubal ligation in the OR and the IUD would be removed in the OR. Once in the OR, the IUD was not found and hysteroscopy was performed to search for the IUD. My question is should the hysteroscopy be coded with a 58558 hysteroscopy D&C or should I consider it a diagnostic hysteroscopy 58555? Here is the op note:
Preoperative Diagnosis:
1. Desires sterilization
2. Desired removal of inrauterine device
Postoperative Diagnosis:
Desires sterilization and no evidence of inrauterine or extrauterine intrauterine device.
Procedure:
1. Laparoscopic sterilization with Falope rings.
2. Hysteroscopy with dilation and curettage to find the intrauterine device.
Findings:
Regular endometrial contour with no evidence of an intrauterine device laparoscopically. Normal-appearing uterus, fallopian tubes, and ovaries with no evidence of extrauterine IUD.
Operative Procedure:
After induction with adequate general anesthesa, the patient was prepped and draped in dorsal lithotomy position. The bladder was emptied of urine with a red rubber catheter. A bivalve speculum was placed and using a blunt grasping instrument an attempt was made to remove the intrauterine device which could not be located in this fashion.
A 1 cm incision was made infraumbilically. A Veress needle was inserted. Placement was verified with a saline-filled syringe. Adequate pneumoperitoneum was achieved with carbon dioxide gas. Ther Veress needle was removed and an 11 mm trocar was inserted in through the umbilical incision. Placement was verified with the laparoscope. The patient was placed in Trendelenburg position, and an 8 mm trocar was inserted suprapubically in the midline under direct visualization.
Using a blunt probe the pelvis was inspected with the above findings noted. Using a disposable Falope ring applicator, a single Falope ring was applied to the narrowest portion of each fallopian tube. A small amount of bipolar electrocautery was applied to the distal portion of the patient's left fallopian tube at the site where the Falope ring was applied due to a small tear in the fallopian tube. No bleeding was noted, but cauterization was performed.
After verifying appropriate placement of the Falope rings on each fallopian tube, the posterior cul-de-sac was inspected, and no intrauterine device or other abnormalities were identified.
Pneumoperitoneum was released. The instruments were removed. The fascia of the umbilical trocar site was closed iwth an interrupted 0 vicryl sutre and both skin incisions were closed with subcuticular 4-0 Vicryl sutures and covered with sterile dressings.
Transvaginally a weighted speculum was placed in the cervix, was placed on traction with a single-tooth tenaculum. Endocervical canal was dilated with graduated dilators to 8 mm. Using a diagnostic hysteroscope the uterine cavity was visualized, and no IUD was identified. A regular endometrial contour was noted. Briefly a sharp curettage was performed in an attempt to determine whether or not the strings could be brought through the os for remvoal. No evidence of an IUD was noted on curettage either.
A transvaginal ultrasound was performed with no evidence of an IUD via ultrasound and no other abnormalities were noted.
Thanks for any input or review!
Claudia
Preoperative Diagnosis:
1. Desires sterilization
2. Desired removal of inrauterine device
Postoperative Diagnosis:
Desires sterilization and no evidence of inrauterine or extrauterine intrauterine device.
Procedure:
1. Laparoscopic sterilization with Falope rings.
2. Hysteroscopy with dilation and curettage to find the intrauterine device.
Findings:
Regular endometrial contour with no evidence of an intrauterine device laparoscopically. Normal-appearing uterus, fallopian tubes, and ovaries with no evidence of extrauterine IUD.
Operative Procedure:
After induction with adequate general anesthesa, the patient was prepped and draped in dorsal lithotomy position. The bladder was emptied of urine with a red rubber catheter. A bivalve speculum was placed and using a blunt grasping instrument an attempt was made to remove the intrauterine device which could not be located in this fashion.
A 1 cm incision was made infraumbilically. A Veress needle was inserted. Placement was verified with a saline-filled syringe. Adequate pneumoperitoneum was achieved with carbon dioxide gas. Ther Veress needle was removed and an 11 mm trocar was inserted in through the umbilical incision. Placement was verified with the laparoscope. The patient was placed in Trendelenburg position, and an 8 mm trocar was inserted suprapubically in the midline under direct visualization.
Using a blunt probe the pelvis was inspected with the above findings noted. Using a disposable Falope ring applicator, a single Falope ring was applied to the narrowest portion of each fallopian tube. A small amount of bipolar electrocautery was applied to the distal portion of the patient's left fallopian tube at the site where the Falope ring was applied due to a small tear in the fallopian tube. No bleeding was noted, but cauterization was performed.
After verifying appropriate placement of the Falope rings on each fallopian tube, the posterior cul-de-sac was inspected, and no intrauterine device or other abnormalities were identified.
Pneumoperitoneum was released. The instruments were removed. The fascia of the umbilical trocar site was closed iwth an interrupted 0 vicryl sutre and both skin incisions were closed with subcuticular 4-0 Vicryl sutures and covered with sterile dressings.
Transvaginally a weighted speculum was placed in the cervix, was placed on traction with a single-tooth tenaculum. Endocervical canal was dilated with graduated dilators to 8 mm. Using a diagnostic hysteroscope the uterine cavity was visualized, and no IUD was identified. A regular endometrial contour was noted. Briefly a sharp curettage was performed in an attempt to determine whether or not the strings could be brought through the os for remvoal. No evidence of an IUD was noted on curettage either.
A transvaginal ultrasound was performed with no evidence of an IUD via ultrasound and no other abnormalities were noted.
Thanks for any input or review!
Claudia