karey
Networker
Please see below OP report. I am having touble assigning an appropriate code.
[FONT=Arial,sans-serif]PROCEDURE:[/FONT]
[FONT=Arial,sans-serif]1. Exam under anesthesia[/FONT]
[FONT=Arial,sans-serif]2. Cervical biopsies[/FONT]
[FONT=Arial,sans-serif]3. Endocervical mass biopsies[/FONT]
[FONT=Arial,sans-serif]4. Endometrial biopsy[/FONT]
[FONT=Arial,sans-serif]5. Right suburethral nodule vaginal biopsy[/FONT]
[FONT=Arial,sans-serif]1. Exam under anesthesia[/FONT]
[FONT=Arial,sans-serif]2. Cervical biopsies[/FONT]
[FONT=Arial,sans-serif]3. Endocervical mass biopsies[/FONT]
[FONT=Arial,sans-serif]4. Endometrial biopsy[/FONT]
[FONT=Arial,sans-serif]5. Right suburethral nodule vaginal biopsy[/FONT]
[FONT=Arial,sans-serif]OPERATIVE PROCEDURE: After appropriate informed consent had been obtained, the patient was taken to the operating room where anesthesia was administered. She was placed in dorsal lithotomy position in the candy cane stirrups and prepared and draped in normal fashion. A time-out was performed with Dr. Copeland in the room to confirm patient identity, planned procedure and the bladder was emptied using the red rubber catheter. Retractors were then placed in the patient's vagina. A large endocervical tumor was seen that was dilating the cervix approximately 8 cm. There appeared to be a thin rim of grossly normal appearing cervix. Biopsies of the normal appearing cervix were taken from all four quadrants. Next a biopsy was obtained from the endocervical tumor. A uterine sound was used to help identify the uterine cavity. Once identified polyp forceps were introduced into the uterine cavity and an endometrial biopsy was obtained with the forceps. Two biopsies were obtained from the suburethral nodule as described above. Hemostasis was achieved through electrocautery at the cervical biopsy sites. Monsel's was then applied to the tumor bed and the vagina was packed. A foley catheter was then placed. Hemostasis appeared satisfactory. The patient was in satisfactory condition on transfer to the recovery room. The patient was reversed from endotracheal anesthesia, and taken to the recovery room in stable condition. All sponge, lap and needle counts were correct X 2. [/FONT]
[FONT=Arial,sans-serif][/FONT]
[FONT=Arial,sans-serif]Obviously the EAU is not billable. Would I code as 58100- Endometrial biopsy? I feel this doesnt represent all of the biopsies performed. He does not say the he dilated the cervix. It states that the mass had dilated the cervix so a D&C would not be appropriate. [/FONT]
[FONT=Arial,sans-serif][/FONT]
[FONT=Arial,sans-serif]Any help would be appreciated
[/FONT]
[FONT=Arial,sans-serif][/FONT]
[FONT=Arial,sans-serif]Obviously the EAU is not billable. Would I code as 58100- Endometrial biopsy? I feel this doesnt represent all of the biopsies performed. He does not say the he dilated the cervix. It states that the mass had dilated the cervix so a D&C would not be appropriate. [/FONT]
[FONT=Arial,sans-serif][/FONT]
[FONT=Arial,sans-serif]Any help would be appreciated
[/FONT]