My coworkers and I are having trouble coming to the appropriate code for the following Op Note. The doctor states CPT codes as 58150, 58661, 57282. We do not find in the note that she performed a Colpopexy. We came to the agreement that 58150 was performed, however, this code for inpatient only and our patient was outpatient. Please help!!
Hysterectomy Laparoscopic convert to open, Laparoscopic Salpingectomy (B), Uterosacral Vault Suspension Operative Note
Diagnosis
Pre-op Diagnosis
* Uterine leiomyoma, unspecified location [D25.9] Post-op Diagnosis
* Uterine leiomyoma, unspecified location [D25.9]
Procedures
Hysterectomy Laparoscopic convert to open
58150 - PR TOTAL ABDOMINAL HYSTERECT W/WO RMVL TUBE OVARY
Laparoscopic Salpingectomy
58661 - PR LAPAROSCOPY W/RMVL ADNEXAL STRUCTURES
Uterosacral Vault Suspension
57282 - PR COLPOPEXY VAGINAL EXTRAPERITONEAL APPROACH
Procedure Summary
Anesthesia: General ASA: II
Estimated Blood Loss: 400 mL
Total IV Fluids: See anesthesia report mL
Drains:
Urethral Catheter Latex 16 Fr. (Active)
Specimens
ID Source Type Tests Collected By Collected At Frozen? Priority Lab ID
A Uterus Tissue SURGICAL PATHOLOGY EXAM
Description: Uterine fibroids
B Uterus Tissue SURGICAL PATHOLOGY EXAM
Description: Uterus, fallopian tube, cervix
Specimen:
ID Type Source Tests Collected by Time
A : Uterine fibroids Tissue Uterus SURGICAL PATHOLOGY EXAM
B : Uterus, fallopian tube, cervix Tissue Uterus SURGICAL PATHOLOGY EXAM
Indications: is an y.o. female who is having surgery for Uterine leiomyoma, unspecified location [D25.9].
Procedure Details:
The patient was seen in the preoperative area. The risks, benefits, complications, treatment options, non-operative alternatives, expected recovery and outcomes were discussed with the patient. The possibilities of reaction to medication, pulmonary aspiration, injury to surrounding structures, bleeding, recurrent infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The site of surgery was properly noted/marked if necessary per policy. Preoperative antibiotics have been ordered and given within 1 hours of incision. Venous thrombosis prophylaxis are not indicated.
Findings: Large fibroid uterus. 12cm posterior cul de sac fibroid adherent to the rectum and pelvic side wall. 5cm pedunculated anterior wall fibroid. 3 cm pedunculated posterior wall fibroid. Normal appearing right ovary and right fallopian tube. Endometriosis noted along the pelvic side wall and uterine body. Bilateral ureteral efflux.
The uterine manipulator was placed without complications. Only the tip of the RUMI was used (size 8) after we sounded the uterus to 8cm with endometrial balloon inflated. Gloves were changed, and attention was directed to the abdomen.
Two Allis clamps were used to evert the umbilicus. A 10-mm incision was created at the level of the umbilicus in a vertical fashion. A Veress needle was utilized to get into the peritoneal axis. Once we were intraperitoneal with low opening presure of 5 mm Hg, we allowed CO2 gas to insufflate her abdomen until we reached a pressure of 15 mmHg. Once we reached that pressure, a 12-mm optical trocar was inserted under direct visualization at this site. Two additional trocars was placed on bilateral lower quadrants approximately 2 fingerbreadths above the anterior superior iliac spine and 2 cm medial to that spot under direct visualization. A 12 mm trocar and a 5 mm trocar were placed on the right and left lower quadrants. The inferior epigastric vessels were visualized prior to trocar insertion in trying to avoid injury to this vessel.
First, a survey of the cavity was performed, and we confirmed the above-mentioned findings. We started a salpingectomy on the right side. The pedicle was ligated and resected with the Ligasure device down to the level of uterine cornua. Next the multiple uterine fibroids were addressed. The smaller pedunculated fibroids were transected from the uterine body. During this portion of the case we noticed the large posterior cul de sac uterine fibroid that was completely adhered to the pelvic side wall, colon and uterus. Prior to address this fibroid attention was turned to control of the uterine blood supply. The broad ligament was taken down to the uterine vessels incorporating the round ligament into the transection. The round ligament was opened on the right side, and we developed the vesicouterine space without complications. We began cautery of the easily visible uterine arteries at the level of the internal cervical os on the right. These uterine arteries were double burned and cut without complications. The same procedure was then performed on the left. Once we secured the uterine arteries bilaterally, we noticed blanching of the uterus. The posterior fibroid was then carefully transected away from the surrounding tissue making sure to avoid injury to the colon, ureters, and bladder. Once blood supply to the fibroid was controled it was removed from the pelvic cavity and placed in the upper abdomen, A laparoscopic J hook bovie tip and then Ligasure device were used to perform the colpotomy. The uterus was completely detached from the vaginal mucosa and surrounding pelvis. The uterus, cervix, fallopian tube was removed from the pelvic cavity.
The decision was made to proceed with mini laparotomy to remove the 12cm calcified fibroid. A small incision was made with 10 blade scalpel approximately 4cm above the pubic symphysis. The incision was carried down to fascia using a Bovie scalpel. The rectus fascia was opened with the bovie. Once we were able to extend the rectus fascia laterally, two kocher clamps were used to retract the fascia which was separated off the rectus muscles sharply. The peritoneal edges were grasped with hemostats and entered sharply. Once we entered the peritoneal cavity, the incision was stretched bluntly. The fibroid was grasped with a single tooth tenaculum and slowly delivered from the abdominal cavity. The mini lap fascia was closed with 0 vicryl. The mini laparotomy subcutaneous fat was closed with 3-0 plaingut suture. The mini laparotomy skin incision was closed with 4-0.
The abdomen was reinsufflated and 2-0 Strataix was used to closed the vaginal cuff. A thourough inspection of the pelvic cavity showed the pelvis to be hemostatic. The camera port was removed once CO2 gas was evacuated from the abdomen and after several Valsalva breaths were given. The skin incisions were closed with 4-0 Monocryl and surgical glue adhesive.
Next cystoscopy was performed. Flow was confirmed and the cystoscope was inserted into the urethra. A scan of the bladder revealed no abnormalities, polyps or lesions. No injury to the bladder mucosa was noted. Bilateral urethral efflux was noted.
No bladder, ureteral, viscus, or solid organ injury were noted at the end of the procedure. There were no complications. The sponge, needle and instrument count were correct x2. The patient tolerated the procedure well and went to the recovery room in stable condition.
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Hysterectomy Laparoscopic convert to open, Laparoscopic Salpingectomy (B), Uterosacral Vault Suspension Operative Note
Diagnosis
Pre-op Diagnosis
* Uterine leiomyoma, unspecified location [D25.9] Post-op Diagnosis
* Uterine leiomyoma, unspecified location [D25.9]
Procedures
Hysterectomy Laparoscopic convert to open
58150 - PR TOTAL ABDOMINAL HYSTERECT W/WO RMVL TUBE OVARY
Laparoscopic Salpingectomy
58661 - PR LAPAROSCOPY W/RMVL ADNEXAL STRUCTURES
Uterosacral Vault Suspension
57282 - PR COLPOPEXY VAGINAL EXTRAPERITONEAL APPROACH
Procedure Summary
Anesthesia: General ASA: II
Estimated Blood Loss: 400 mL
Total IV Fluids: See anesthesia report mL
Drains:
Urethral Catheter Latex 16 Fr. (Active)
Specimens
ID Source Type Tests Collected By Collected At Frozen? Priority Lab ID
A Uterus Tissue SURGICAL PATHOLOGY EXAM
Description: Uterine fibroids
B Uterus Tissue SURGICAL PATHOLOGY EXAM
Description: Uterus, fallopian tube, cervix
Specimen:
ID Type Source Tests Collected by Time
A : Uterine fibroids Tissue Uterus SURGICAL PATHOLOGY EXAM
B : Uterus, fallopian tube, cervix Tissue Uterus SURGICAL PATHOLOGY EXAM
Indications: is an y.o. female who is having surgery for Uterine leiomyoma, unspecified location [D25.9].
Procedure Details:
The patient was seen in the preoperative area. The risks, benefits, complications, treatment options, non-operative alternatives, expected recovery and outcomes were discussed with the patient. The possibilities of reaction to medication, pulmonary aspiration, injury to surrounding structures, bleeding, recurrent infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The site of surgery was properly noted/marked if necessary per policy. Preoperative antibiotics have been ordered and given within 1 hours of incision. Venous thrombosis prophylaxis are not indicated.
Findings: Large fibroid uterus. 12cm posterior cul de sac fibroid adherent to the rectum and pelvic side wall. 5cm pedunculated anterior wall fibroid. 3 cm pedunculated posterior wall fibroid. Normal appearing right ovary and right fallopian tube. Endometriosis noted along the pelvic side wall and uterine body. Bilateral ureteral efflux.
The uterine manipulator was placed without complications. Only the tip of the RUMI was used (size 8) after we sounded the uterus to 8cm with endometrial balloon inflated. Gloves were changed, and attention was directed to the abdomen.
Two Allis clamps were used to evert the umbilicus. A 10-mm incision was created at the level of the umbilicus in a vertical fashion. A Veress needle was utilized to get into the peritoneal axis. Once we were intraperitoneal with low opening presure of 5 mm Hg, we allowed CO2 gas to insufflate her abdomen until we reached a pressure of 15 mmHg. Once we reached that pressure, a 12-mm optical trocar was inserted under direct visualization at this site. Two additional trocars was placed on bilateral lower quadrants approximately 2 fingerbreadths above the anterior superior iliac spine and 2 cm medial to that spot under direct visualization. A 12 mm trocar and a 5 mm trocar were placed on the right and left lower quadrants. The inferior epigastric vessels were visualized prior to trocar insertion in trying to avoid injury to this vessel.
First, a survey of the cavity was performed, and we confirmed the above-mentioned findings. We started a salpingectomy on the right side. The pedicle was ligated and resected with the Ligasure device down to the level of uterine cornua. Next the multiple uterine fibroids were addressed. The smaller pedunculated fibroids were transected from the uterine body. During this portion of the case we noticed the large posterior cul de sac uterine fibroid that was completely adhered to the pelvic side wall, colon and uterus. Prior to address this fibroid attention was turned to control of the uterine blood supply. The broad ligament was taken down to the uterine vessels incorporating the round ligament into the transection. The round ligament was opened on the right side, and we developed the vesicouterine space without complications. We began cautery of the easily visible uterine arteries at the level of the internal cervical os on the right. These uterine arteries were double burned and cut without complications. The same procedure was then performed on the left. Once we secured the uterine arteries bilaterally, we noticed blanching of the uterus. The posterior fibroid was then carefully transected away from the surrounding tissue making sure to avoid injury to the colon, ureters, and bladder. Once blood supply to the fibroid was controled it was removed from the pelvic cavity and placed in the upper abdomen, A laparoscopic J hook bovie tip and then Ligasure device were used to perform the colpotomy. The uterus was completely detached from the vaginal mucosa and surrounding pelvis. The uterus, cervix, fallopian tube was removed from the pelvic cavity.
The decision was made to proceed with mini laparotomy to remove the 12cm calcified fibroid. A small incision was made with 10 blade scalpel approximately 4cm above the pubic symphysis. The incision was carried down to fascia using a Bovie scalpel. The rectus fascia was opened with the bovie. Once we were able to extend the rectus fascia laterally, two kocher clamps were used to retract the fascia which was separated off the rectus muscles sharply. The peritoneal edges were grasped with hemostats and entered sharply. Once we entered the peritoneal cavity, the incision was stretched bluntly. The fibroid was grasped with a single tooth tenaculum and slowly delivered from the abdominal cavity. The mini lap fascia was closed with 0 vicryl. The mini laparotomy subcutaneous fat was closed with 3-0 plaingut suture. The mini laparotomy skin incision was closed with 4-0.
The abdomen was reinsufflated and 2-0 Strataix was used to closed the vaginal cuff. A thourough inspection of the pelvic cavity showed the pelvis to be hemostatic. The camera port was removed once CO2 gas was evacuated from the abdomen and after several Valsalva breaths were given. The skin incisions were closed with 4-0 Monocryl and surgical glue adhesive.
Next cystoscopy was performed. Flow was confirmed and the cystoscope was inserted into the urethra. A scan of the bladder revealed no abnormalities, polyps or lesions. No injury to the bladder mucosa was noted. Bilateral urethral efflux was noted.
No bladder, ureteral, viscus, or solid organ injury were noted at the end of the procedure. There were no complications. The sponge, needle and instrument count were correct x2. The patient tolerated the procedure well and went to the recovery room in stable condition.
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable