Girlzsmom66
Guru
This is what I have determined...please let me know if I have coded incorrectly:
ICD 10 N85.9 and CPT 58558
Brief consult
General Note
Patient had sonohysterogram today which demonstrated band of tissue that represents residual POC vs synechium vs debris.
Hysteroscopy is recommended. Will try to schedule later this week as the patient is on OCPs.
ADDENDA DETAILS:
Encounter Background Information: Patietn presents s/p spontaneous abortion for sonohysterogram to rule out residual POC or recurrent
adhesions.
Therapy
Procedure: Sonohysterogram
Patient was placed on the examining table in the dorsal lithotomy position. Transvaginal ultrasound was done and endometrium was noted to be 3.35
mm in A-P thickness with a homogenous patten. Speculum was placed. Cervix and vagina were cleaned with Betadine. A disposable HSG
catheter was placed transcervically with instillation of 1 cc sterile saline into the catheter balloon. The speculum was subsequently removed followed
by placement of the transvaginal probe. Sterile normal saline was then injected into the uterine lumen using 2D & 3D ultrasound visualization. The
uterine lumen has normal contour, but there is a persistent band of tissue coursing diagonally from right to left across the mid-body. The balloon was
then deflated and removed. The patient appeared to tolerate the procedure well, without complications.
Impression:
Normal uterine contour
Band of tissue consistent with residual POC vs adhesion, vs debris.
Assessment
• Recurrent pregnancy loss (non-gravid)
• Pregnancy test was performed
ICD 10 N85.9 and CPT 58558
Brief consult
General Note
Patient had sonohysterogram today which demonstrated band of tissue that represents residual POC vs synechium vs debris.
Hysteroscopy is recommended. Will try to schedule later this week as the patient is on OCPs.
ADDENDA DETAILS:
Encounter Background Information: Patietn presents s/p spontaneous abortion for sonohysterogram to rule out residual POC or recurrent
adhesions.
Therapy
Procedure: Sonohysterogram
Patient was placed on the examining table in the dorsal lithotomy position. Transvaginal ultrasound was done and endometrium was noted to be 3.35
mm in A-P thickness with a homogenous patten. Speculum was placed. Cervix and vagina were cleaned with Betadine. A disposable HSG
catheter was placed transcervically with instillation of 1 cc sterile saline into the catheter balloon. The speculum was subsequently removed followed
by placement of the transvaginal probe. Sterile normal saline was then injected into the uterine lumen using 2D & 3D ultrasound visualization. The
uterine lumen has normal contour, but there is a persistent band of tissue coursing diagonally from right to left across the mid-body. The balloon was
then deflated and removed. The patient appeared to tolerate the procedure well, without complications.
Impression:
Normal uterine contour
Band of tissue consistent with residual POC vs adhesion, vs debris.
Assessment
• Recurrent pregnancy loss (non-gravid)
• Pregnancy test was performed
