rockylopez
Networker
Hello. I am coding for a cosurgeon case and I am stuck with coding what was initially laparoscopic and converted to open. The op report is confusing in determining how i should code the procedure I am gearing towards 49000 but really could use some help. Thank you
PROCEDURE in DETAIL:
Upon entering room, evaluated by laparoscopy large complex right ovarian mass with both solid and cystic components. I went ahead and scrubbed
to better take a look. pt is postmenopausal with ascites and what could be b/l ovarian fibromas, vs neoplasm. right ovary with enlarged cyst was
noted and using Harmonic scalpel IP identified and ovary with cyst was excised.
Using already a vertical supraumbilical skin incision which was already made was used to enter the peritoneal cavity and remove the large right
complex solid and cystic ovary which measures ~ 15 x 13 x 11 cm was removed intact through this incision. This uterus and left ovary were also
palpated through this incision and also left ovary was found to have a large adnexal mass as well also with solid and cystic components. using the
vertical supraumbilical midline incision, this incision was extended inferiorly to allow better exposure and access to left adnexa. uterus was 4 cm x 4
cm is size, normal appearing with small anterior fibroid, otherwise normal. left ovary with 10 x 6 x 8 cm complex adnexal mass. left IP identified
and both left tube and ovary with enlarged cyst was excised using Kelly clamps. pedicle was suture ligated with 0 Vicryl in transfixion suture x 2.
and specimen of left tube and left ovary with complex cyst was taken off field and also will be sent to path for permanent
Hemostasis noted at both sites of pedicles.
My part of procedure was completed and I remained to assist Dr. in further exploration, umbilical hernia repair, abdominal wall closure. See
remainder of details in the OP note.
Pathology: right ovary with enlarged complex cyst and left ovary with large complex cyst and left tube
PROCEDURE in DETAIL:
Upon entering room, evaluated by laparoscopy large complex right ovarian mass with both solid and cystic components. I went ahead and scrubbed
to better take a look. pt is postmenopausal with ascites and what could be b/l ovarian fibromas, vs neoplasm. right ovary with enlarged cyst was
noted and using Harmonic scalpel IP identified and ovary with cyst was excised.
Using already a vertical supraumbilical skin incision which was already made was used to enter the peritoneal cavity and remove the large right
complex solid and cystic ovary which measures ~ 15 x 13 x 11 cm was removed intact through this incision. This uterus and left ovary were also
palpated through this incision and also left ovary was found to have a large adnexal mass as well also with solid and cystic components. using the
vertical supraumbilical midline incision, this incision was extended inferiorly to allow better exposure and access to left adnexa. uterus was 4 cm x 4
cm is size, normal appearing with small anterior fibroid, otherwise normal. left ovary with 10 x 6 x 8 cm complex adnexal mass. left IP identified
and both left tube and ovary with enlarged cyst was excised using Kelly clamps. pedicle was suture ligated with 0 Vicryl in transfixion suture x 2.
and specimen of left tube and left ovary with complex cyst was taken off field and also will be sent to path for permanent
Hemostasis noted at both sites of pedicles.
My part of procedure was completed and I remained to assist Dr. in further exploration, umbilical hernia repair, abdominal wall closure. See
remainder of details in the OP note.
Pathology: right ovary with enlarged complex cyst and left ovary with large complex cyst and left tube