Wiki Mini Laparotomy post partum tubal

[astough]

Could someone please give me an opinion on coding the following report? It is a post partum mini laparotomy tubal. Insurance says that the note doesn't support the code that I billed which was 58605. Thanks in advance for any input on this.

Preop Diagnosis: Female requesting permanent sterilization

Post op Diagnosis: Female requesting permanent sterilization

Procedure: Mini-laparotomy tubal postpartum

Findings: the uterus was at the umbilicus. On entrance into the abdomen the tubes were identified to the fimbria. Isthmic portions of 1.5-2 cm were taken bilaterally without difficulty.

Procedure: The patient was taken to the OR, prepped and draped in the usual fashion. We dissected down through skin, subcutaneous tissue, fascia, through the peritoneum bluntly. Using Army-Navy's we isolated the tubes bilaterally and performed Pomeroy sterilization without difficulty with tow 1 plain ties. No complications were encountered. Sponge counts correct. the peritoneum was closed with a running 0 Viscryl, the fascia with 1 Viscryl interrupted, the skin with Monocryl and Steri-Strips. The patient was taken to recovery room with stable vitals.

Thanks so much!!

Angie

 

[dpetersen]

Was the procedure done during the same hospital stay as the vaginal delivery? If so, then I think 58605 would be correct. If the procedure was not done during the same hospital stay, then I use 58600. Hope this helps.