Please help. I'm thinking this is an unlisted procedure code 58999. I don't think it's 58145 Myomectomy vaginal approach. Any advice greatly appreciated.
The report reads:
POSTOPERATIVE DIAGNOSIS: Symptomatic cervical pedunculated fibroid.
PROCEDURE PERFORMED: Vaginal removal of fibroid.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 10 cc.
URINE OUTPUT: 100 cc.
FLUIDS: 400 cc of crystalloid.
FINDINGS: A 4 cm pedunculated cervical fibroid, dilated cervix.
INDICATIONS FOR PROCEDURE: The patient is a 42-year-old with symptomatic cervical fibroid. She has had heavy periods and passage of clot between periods for several months. She had been seen 2 to 3 months ago and counseled on need for surgical management. She was asked to follow up until recently where again she returned with heavy bleeding, and preop labs showing anemia, was counseled on need for removal, and has elected to proceed. She was counseled extensively on risks, benefits, alternatives to procedure, including risk of definitive surgery if bleeding was not able to be contained at the time of surgery.
OPERATIVE COURSE: The patient was taken to the operating room where general anesthesia was found to be adequate. She was prepped and draped in normal sterile fashion. The bladder was cleared of 100 cc of urine and legs were placed in Allen stirrups. A weighted speculum was then inserted vaginally and using a Jacobs retractor, the fibroid was grasped with tension. The pedicle was able to be identified and delivered through the cervix. A Heaney clamp was then placed around the pedicle. A single suture of 0 Vicryl was then placed around the pedicle. Bleeding was hemostatic. A final inspection demonstrated no additional bleeding, and the pedicle was sore within the cervical canal. All instrumentation was then removed from the vaginal canal. All sponge, lap, needle counts were correct x2 and the patient was transferred to recovery room in stable condition.
The report reads:
POSTOPERATIVE DIAGNOSIS: Symptomatic cervical pedunculated fibroid.
PROCEDURE PERFORMED: Vaginal removal of fibroid.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 10 cc.
URINE OUTPUT: 100 cc.
FLUIDS: 400 cc of crystalloid.
FINDINGS: A 4 cm pedunculated cervical fibroid, dilated cervix.
INDICATIONS FOR PROCEDURE: The patient is a 42-year-old with symptomatic cervical fibroid. She has had heavy periods and passage of clot between periods for several months. She had been seen 2 to 3 months ago and counseled on need for surgical management. She was asked to follow up until recently where again she returned with heavy bleeding, and preop labs showing anemia, was counseled on need for removal, and has elected to proceed. She was counseled extensively on risks, benefits, alternatives to procedure, including risk of definitive surgery if bleeding was not able to be contained at the time of surgery.
OPERATIVE COURSE: The patient was taken to the operating room where general anesthesia was found to be adequate. She was prepped and draped in normal sterile fashion. The bladder was cleared of 100 cc of urine and legs were placed in Allen stirrups. A weighted speculum was then inserted vaginally and using a Jacobs retractor, the fibroid was grasped with tension. The pedicle was able to be identified and delivered through the cervix. A Heaney clamp was then placed around the pedicle. A single suture of 0 Vicryl was then placed around the pedicle. Bleeding was hemostatic. A final inspection demonstrated no additional bleeding, and the pedicle was sore within the cervical canal. All instrumentation was then removed from the vaginal canal. All sponge, lap, needle counts were correct x2 and the patient was transferred to recovery room in stable condition.