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Can someone please help me with this one, not sure how to code this one.
Here is the doctors dictation:
Upon entering the abdomen, a large tumor is found,. Tumor is soft an shiny surface, hard. It extends from the pelvis just below the diaphragm. Diaphragm is pushed up because of the enormity of the tumor. The tumor was big enough to be removed intact to any kind of incision, so at this time a small incision into the tumor was made and suction was introduced. When suction was started to collect the fluid, it was completely clear fluid like water 13,500 mL of fluids was drained and finally the sac was removed. Upon examination, it was realized that the sac was hydrosalpinx. Fimbrial ends could not be identified. They were expanded and extended. the end of the tube was recognized and multiple clamps were applied to save the ovary and to remove the rest of the tumor more or less intact with the exception of 2 holes after #1 Monocryl was used for all the pedicles.
The doctor listed the procedures as a Right Salpingectomy, looks like there should be more than that here.
Any help that anyone can give me would be greatly appreciated.
Thanks
Lisa Walker
Here is the doctors dictation:
Upon entering the abdomen, a large tumor is found,. Tumor is soft an shiny surface, hard. It extends from the pelvis just below the diaphragm. Diaphragm is pushed up because of the enormity of the tumor. The tumor was big enough to be removed intact to any kind of incision, so at this time a small incision into the tumor was made and suction was introduced. When suction was started to collect the fluid, it was completely clear fluid like water 13,500 mL of fluids was drained and finally the sac was removed. Upon examination, it was realized that the sac was hydrosalpinx. Fimbrial ends could not be identified. They were expanded and extended. the end of the tube was recognized and multiple clamps were applied to save the ovary and to remove the rest of the tumor more or less intact with the exception of 2 holes after #1 Monocryl was used for all the pedicles.
The doctor listed the procedures as a Right Salpingectomy, looks like there should be more than that here.
Any help that anyone can give me would be greatly appreciated.
Thanks
Lisa Walker
Last edited: