PRINCESSMHH
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DX: urinary retention and erosion of suture
Procedures: Excision of the mass material and urethrolysis
Patient has dx of urinary retention and erosion of suture. This patient had a cystourethropexy/TVT. Findings were small amounts of Prolene suture in the vagina, complete urethral mobility at the completion of surgery.
Vaginal surgery to the anterior wall of the vagina where 2 Allis clamps were placed. Vertical incision made through mucosa to the underlying and to pelvic fascia. Mucosa was dissected away with sharp dissection until the pubic symphysis is reached. The urogenital diaphragm was pierced and the area behind the pubic symphysis/space of Retzius was entered. Prolene sutures were excised in their entirety as they extended down to the vagina. Posterorior aspect of the pubic symphysis was papated from the obturator foramen to the pubic symphysis over the top of the urethra. The vaginal mucosa was then closed with 2-0 Vicryl suture in a running fashion. Excellent hemostasis. Cystoscopy was performed at this point showing no evidence of damage to the bladder or urethra. The patient was taken out of the lithotomy position, awakened from anesthesia, and taken to the Recovery Room in excellent condition.
This is how I coded this report:
ICD-9: 788.20, 996.76
CPT: 57295, 53899 (no modifier because it is unlisted code)
Any suggestions???
Procedures: Excision of the mass material and urethrolysis
Patient has dx of urinary retention and erosion of suture. This patient had a cystourethropexy/TVT. Findings were small amounts of Prolene suture in the vagina, complete urethral mobility at the completion of surgery.
Vaginal surgery to the anterior wall of the vagina where 2 Allis clamps were placed. Vertical incision made through mucosa to the underlying and to pelvic fascia. Mucosa was dissected away with sharp dissection until the pubic symphysis is reached. The urogenital diaphragm was pierced and the area behind the pubic symphysis/space of Retzius was entered. Prolene sutures were excised in their entirety as they extended down to the vagina. Posterorior aspect of the pubic symphysis was papated from the obturator foramen to the pubic symphysis over the top of the urethra. The vaginal mucosa was then closed with 2-0 Vicryl suture in a running fashion. Excellent hemostasis. Cystoscopy was performed at this point showing no evidence of damage to the bladder or urethra. The patient was taken out of the lithotomy position, awakened from anesthesia, and taken to the Recovery Room in excellent condition.
This is how I coded this report:
ICD-9: 788.20, 996.76
CPT: 57295, 53899 (no modifier because it is unlisted code)
Any suggestions???
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