Wiki In-office procedure note

[BS&SC]

5mm rigid hysteroscope was used, saline was used for distention.
A specimen was sent to pathology.

Note reads: pt in or iv sed given pelvic wnl labial lesion noted as well as whitish area periurethral dx scope place into uterine cavity using saline nl findings D and C done dilated #15 tissue to path nova sure device placed cavity length 5 cm width 3.8 cavity assessment test passed under power of 105 for 58 sec dev ablated lower I labia major infiltrated with xylocaine entire lesion which was about 2x3 cm was excised areas sutured with 4-0 vicryl ebb 1cc tissue to path periurethral area infiltrated with xylocaine 5 mm bx taken using scissors scissors used to excise labial lesion also tissue to path no complications Endometrial biopsy performed.

Gravity feed used.
Fluid deficit: 50 ml
Product: TNovaSure

Indications for this procedure
VIN III (vulvar intraepithelial neoplasia III) D07.1
Vulvar lesion N90.89

The biopsy site was vulva. The lesion are I labial major lesion 3cm The skin was prepped with Betadine. The anesthetic used was Lido 2 percent w/wpi, 1-2 mL. The device type used was scissors. The device size was 30 mm. Hemostasis achieved with suture.

Comment: bx of periurethral lesion about 5mm done also used agno3 for hemostasis

58563 N92.0
11626 D07.1 59 (based on 2x3 cm documentation)(Previous visit states this lesion was previously bx and would be excised at this procedure)
56605 N90.89 51
81025 Z30.2 (because the very top of the report does state a routine pregnancy test was done and was found to be negative.)

I was having one of those days where the more I read the note, the more confused with all the sizes. Would love input on how to better break down a note like this.

 

[nielynco]

5mm rigid hysteroscope was used, saline was used for distention.
A specimen was sent to pathology.

Note reads: pt in or iv sed given pelvic wnl labial lesion noted as well as whitish area periurethral dx scope place into uterine cavity using saline nl findings D and C done dilated #15 tissue to path nova sure device placed cavity length 5 cm width 3.8 cavity assessment test passed under power of 105 for 58 sec dev ablated lower I labia major infiltrated with xylocaine entire lesion which was about 2x3 cm was excised areas sutured with 4-0 vicryl ebb 1cc tissue to path periurethral area infiltrated with xylocaine 5 mm bx taken using scissors scissors used to excise labial lesion also tissue to path no complications Endometrial biopsy performed.

Gravity feed used.
Fluid deficit: 50 ml
Product: TNovaSure

Indications for this procedure
VIN III (vulvar intraepithelial neoplasia III) D07.1
Vulvar lesion N90.89

The biopsy site was vulva. The lesion are I labial major lesion 3cm The skin was prepped with Betadine. The anesthetic used was Lido 2 percent w/wpi, 1-2 mL. The device type used was scissors. The device size was 30 mm. Hemostasis achieved with suture.

Comment: bx of periurethral lesion about 5mm done also used agno3 for hemostasis

58563 N92.0
11626 D07.1 59 (based on 2x3 cm documentation)(Previous visit states this lesion was previously bx and would be excised at this procedure)
56605 N90.89 51
81025 Z30.2 (because the very top of the report does state a routine pregnancy test was done and was found to be negative.)

I was having one of those days where the more I read the note, the more confused with all the sizes. Would love input on how to better break down a note like this.

58563 is correct for the ablation and D&C, but 11626 is not the correct code given the lesion size. You do not multiply the dimension or add them, you pick the code based on the widest margin. In this case it was 3 cm so the code would be 11623. You only bill for the pregnancy test if this was performed by the practice - as she was in the OR per the op note, it would be a cost born by the facility, not the MD who performed the procedure and as such should not be billed. Billing 56605 for the biopsy of the additional lesion is also correct.