maine4me
Guru
I was asked to review a denial for a gynecological surgery. The patient had a transvaginal hysterectomy and anterior and posterior colporrhaphy, this was coded as 58260 and 57260. The 57260 (combined anteroposterior colporrhaphy was denied stating that these procedures should not be billed together. I went throught the CPT book thinking maybe there was a combination code and was not sure if it should be 58267 or 58270. Any help is appreciated. Operative report is below.
DATE: 2/24/15
PREOPERATIVE DIAGNOSIS:
1. Uterine prolapse.
2. Cystocele.
3. Rectocele.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE:
1. Transvaginal hysterectomy.
2. Anterior colporrhaphy.
3. Posterior colporrhaphy.
INDICATION: The patient is a 55-year-old, gravida 3, para 3, who presented to the office
with complaints of vaginal prolapse. Evaluation revealed a moderate cystocele, small to
moderate rectocele, and second-degree uterine prolapse. This has become more symptomatic
over time. She also has difficulty with her bowel movements. She has no bladder
dysfunction. After thorough counseling in the office, the decision was made to proceed
with transvaginal hysterectomy and anterior and posterior colporrhaphy. The procedures
were discussed in detail and the patient was counseled on risks, recovery and potential
failure rate. Informed consent was obtained.
SURGEON: C K, M.D.
ASSISTANT: E H, M.D.
ANESTHESIA: General with intubation. Anesthesiologist G D, M.D. and J S, CRNA.
ESTIMATED BLOOD LOSS: 100 cc.
FLUIDS: 2 liters of crystalloid.
SPECIMEN: Uterus.
DRAINS: Foley catheter.
COMPLICATIONS: None seen.
VTE PROPHYLAXIS: Knee-high Venodynes.
OPERATIVE FINDINGS: Second to third-degree uterine prolapse was noted and the uterus was
small and anteverted. There was a moderate to large cystocele to the introitus. There was
a moderate distal rectocele. There was no apparent enterocele. There was good lateral
vaginal support.
PROCEDURE IN DETAIL: The patient was taken to the Operating Room with an IV and general
anesthesia induced with intubation. She was placed in a modified dorsal lithotomy
position with her legs in Yellofin stirrups well flexed but minimally abducted at the
hips. Care was taken to place arms at her sides with no excessive extension. A time out
was done and she was identified on the table. She received 1 gram of Ancef preoperatively
for prophylaxis. Exam under anesthesia was performed and findings as noted. She was
prepped and draped in a sterile fashion.
The cervix was then grasped with two double-tooth tenacula. 10 cc of 1% lidocaine with
1:100,000 epinephrine was infiltrated circumferentially at the cervicovaginal junction. A
circumferential incision was then made 1 to 2 mm proximal to the cervicovaginal junction.
Anteriorly, the vesicocervical space was dissected until peritoneum visualized and the
anterior cul-de-sac entered sharply. This procedure was repeated posteriorly to enter the
posterior cul-de-sac. The uterosacral ligaments were then clamped, transected, and
ligated with 0 Vicryl suture. This bite incorporated a portion of the cardinal ligaments
as well. These suture ends were held long for later use. The uterus was quite small. The
uterine vasculature was then clamped, transected, and ligated with 0 Vicryl suture. The
broad ligaments bilaterally were then clamped, transected, and ligated. The uterine
cornual attachments were then clamped, transected, and ligated with 0 Vicryl suture; this
required two bites on each side. The uterus and cervix were removed in their entirety and
sent to pathology. All pedicles were visualized and excellent hemostasis noted. Free Mayo
needle was used to draw the free ends of the uterosacral cardinal ligament complex
through the angle of the vaginal mucosa. This was done bilaterally and again held for
later tying. McCall's culdoplasty was performed using 2-0 Vicryl by starting on the outer
vaginal cuff to the patient's left and bringing the suture from the vagina to
intra-abdominal. It was then carried through the peritoneum to the left cardinal ligament
complex. The suture then incorporated the left cardinal ligament complex and was brought
towards the midline and right but taking serial bites in the peritoneum. It was then
brought through the right cardinal ligament pedicle and the right side of the posterior
vaginal cuff into the vagina. These ends were held for later use. The vaginal cuff was
then closed by first placing 0 Vicryl figure-of-eight angle sutures, followed by a
running locked 0 Vicryl suture, taking care to incorporate full thickness of the vaginal
cuff and the peritoneal edge. The suture ends from the uterosacral cardinal ligament
complex that were brought through the angles were then tied down bilaterally. The
culdoplasty suture was tied down. This brought the vaginal cuff more apical with better
support.
Attention was turned to the cystocele. Allis clamps were used to grasp the anterior
vaginal mucosa at the vaginal cuff at the midline. 10 cc of 1% lidocaine with 1:100,000
epinephrine was infiltrated submucosally at the midline. The anterior vaginal mucosa was
then incised from the vaginal cuff to within 2 cm of the urethral meatus. The mucosa was
then dissected from the underlying endopelvic fascia with sharp and blunt dissection. The
dissection was carried laterally to the lateral limits of the cystocele. The cystocele
was then reduced starting at the bladder neck using a 2-0 PDS. Horizontal mattress
sutures were used to plicate the lateral fascia at the midline. This was completed with a
pursestring suture proximally. Excellent reduction of the cystocele was obtained. Care
was taken to avoid excessive stricture on the urethra. Foley catheter had been placed
prior to the procedure and urine remained clear at this time. The vaginal mucosa was
trimmed and reapproximated with a running 2-0 Vicryl suture.
Attention was turned posteriorly. Two Allis clamps were used to grasp the vaginal mucosa
in the vestibule at the midline. 10 cc of 1% lidocaine with 1:100,000 epinephrine was
infiltrated at the midline of the posterior vaginal mucosa. A stab wound was made in the
vestibule and the mucosa undermined to within 1 to 2 cm of the vaginal cuff. The mucosa
was then incised and dissected from the underlying endopelvic fascia. The rectocele was
reduced using 2-0 PDS imbricating the lateral healthier fascial tissue in the midline.
Distally, this repair incorporated the levator ani muscles for support. The posterior
vaginal mucosa was then trimmed and reapproximated with a running 2-0 Vicryl suture.
Vaginal exam was performed and excellent two-finger caliber was noted and good apical
support noted. Rectal exam was performed and good support was noted there and no breech
of the rectal mucosa with suture was palpated. Foley catheter was left indwelling and
urine remained clear. Betadine soaked vaginal packing was placed. The patient tolerated
the procedure well. She was awakened and extubated in the Operating Room and transported
to recovery in stable condition. Knee-high Venodynes were left on for VTE prophylaxis.
DATE: 2/24/15
PREOPERATIVE DIAGNOSIS:
1. Uterine prolapse.
2. Cystocele.
3. Rectocele.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE:
1. Transvaginal hysterectomy.
2. Anterior colporrhaphy.
3. Posterior colporrhaphy.
INDICATION: The patient is a 55-year-old, gravida 3, para 3, who presented to the office
with complaints of vaginal prolapse. Evaluation revealed a moderate cystocele, small to
moderate rectocele, and second-degree uterine prolapse. This has become more symptomatic
over time. She also has difficulty with her bowel movements. She has no bladder
dysfunction. After thorough counseling in the office, the decision was made to proceed
with transvaginal hysterectomy and anterior and posterior colporrhaphy. The procedures
were discussed in detail and the patient was counseled on risks, recovery and potential
failure rate. Informed consent was obtained.
SURGEON: C K, M.D.
ASSISTANT: E H, M.D.
ANESTHESIA: General with intubation. Anesthesiologist G D, M.D. and J S, CRNA.
ESTIMATED BLOOD LOSS: 100 cc.
FLUIDS: 2 liters of crystalloid.
SPECIMEN: Uterus.
DRAINS: Foley catheter.
COMPLICATIONS: None seen.
VTE PROPHYLAXIS: Knee-high Venodynes.
OPERATIVE FINDINGS: Second to third-degree uterine prolapse was noted and the uterus was
small and anteverted. There was a moderate to large cystocele to the introitus. There was
a moderate distal rectocele. There was no apparent enterocele. There was good lateral
vaginal support.
PROCEDURE IN DETAIL: The patient was taken to the Operating Room with an IV and general
anesthesia induced with intubation. She was placed in a modified dorsal lithotomy
position with her legs in Yellofin stirrups well flexed but minimally abducted at the
hips. Care was taken to place arms at her sides with no excessive extension. A time out
was done and she was identified on the table. She received 1 gram of Ancef preoperatively
for prophylaxis. Exam under anesthesia was performed and findings as noted. She was
prepped and draped in a sterile fashion.
The cervix was then grasped with two double-tooth tenacula. 10 cc of 1% lidocaine with
1:100,000 epinephrine was infiltrated circumferentially at the cervicovaginal junction. A
circumferential incision was then made 1 to 2 mm proximal to the cervicovaginal junction.
Anteriorly, the vesicocervical space was dissected until peritoneum visualized and the
anterior cul-de-sac entered sharply. This procedure was repeated posteriorly to enter the
posterior cul-de-sac. The uterosacral ligaments were then clamped, transected, and
ligated with 0 Vicryl suture. This bite incorporated a portion of the cardinal ligaments
as well. These suture ends were held long for later use. The uterus was quite small. The
uterine vasculature was then clamped, transected, and ligated with 0 Vicryl suture. The
broad ligaments bilaterally were then clamped, transected, and ligated. The uterine
cornual attachments were then clamped, transected, and ligated with 0 Vicryl suture; this
required two bites on each side. The uterus and cervix were removed in their entirety and
sent to pathology. All pedicles were visualized and excellent hemostasis noted. Free Mayo
needle was used to draw the free ends of the uterosacral cardinal ligament complex
through the angle of the vaginal mucosa. This was done bilaterally and again held for
later tying. McCall's culdoplasty was performed using 2-0 Vicryl by starting on the outer
vaginal cuff to the patient's left and bringing the suture from the vagina to
intra-abdominal. It was then carried through the peritoneum to the left cardinal ligament
complex. The suture then incorporated the left cardinal ligament complex and was brought
towards the midline and right but taking serial bites in the peritoneum. It was then
brought through the right cardinal ligament pedicle and the right side of the posterior
vaginal cuff into the vagina. These ends were held for later use. The vaginal cuff was
then closed by first placing 0 Vicryl figure-of-eight angle sutures, followed by a
running locked 0 Vicryl suture, taking care to incorporate full thickness of the vaginal
cuff and the peritoneal edge. The suture ends from the uterosacral cardinal ligament
complex that were brought through the angles were then tied down bilaterally. The
culdoplasty suture was tied down. This brought the vaginal cuff more apical with better
support.
Attention was turned to the cystocele. Allis clamps were used to grasp the anterior
vaginal mucosa at the vaginal cuff at the midline. 10 cc of 1% lidocaine with 1:100,000
epinephrine was infiltrated submucosally at the midline. The anterior vaginal mucosa was
then incised from the vaginal cuff to within 2 cm of the urethral meatus. The mucosa was
then dissected from the underlying endopelvic fascia with sharp and blunt dissection. The
dissection was carried laterally to the lateral limits of the cystocele. The cystocele
was then reduced starting at the bladder neck using a 2-0 PDS. Horizontal mattress
sutures were used to plicate the lateral fascia at the midline. This was completed with a
pursestring suture proximally. Excellent reduction of the cystocele was obtained. Care
was taken to avoid excessive stricture on the urethra. Foley catheter had been placed
prior to the procedure and urine remained clear at this time. The vaginal mucosa was
trimmed and reapproximated with a running 2-0 Vicryl suture.
Attention was turned posteriorly. Two Allis clamps were used to grasp the vaginal mucosa
in the vestibule at the midline. 10 cc of 1% lidocaine with 1:100,000 epinephrine was
infiltrated at the midline of the posterior vaginal mucosa. A stab wound was made in the
vestibule and the mucosa undermined to within 1 to 2 cm of the vaginal cuff. The mucosa
was then incised and dissected from the underlying endopelvic fascia. The rectocele was
reduced using 2-0 PDS imbricating the lateral healthier fascial tissue in the midline.
Distally, this repair incorporated the levator ani muscles for support. The posterior
vaginal mucosa was then trimmed and reapproximated with a running 2-0 Vicryl suture.
Vaginal exam was performed and excellent two-finger caliber was noted and good apical
support noted. Rectal exam was performed and good support was noted there and no breech
of the rectal mucosa with suture was palpated. Foley catheter was left indwelling and
urine remained clear. Betadine soaked vaginal packing was placed. The patient tolerated
the procedure well. She was awakened and extubated in the Operating Room and transported
to recovery in stable condition. Knee-high Venodynes were left on for VTE prophylaxis.