Wiki Sacrospinous ligament suspension removal

[dmarshall]

Hello OB/GYN Coders,

Need your assistance with the CPT code for this procedure performed in the office please:

Date/Time:0:00 AM Performed by: Dr Who; Verbal consent obtained. Written consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Procedure consent: procedure consent matches procedure scheduled Relevant documents: relevant documents present and verified Patient identity confirmed: verbally with patient Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Local anesthesia used: yes Anesthesia: local infiltration Anesthesia :Local anesthesia used: yes Local Anesthetic: lidocaine 2% without epinephrine Anesthetic total: 5 mL Sedation patient sedated: yes Sedation type: moderate (conscious) sedation Sedatives: see MAR for details Analgesia: see MAR for details Vitals: Vital signs were monitored during sedation. Patient tolerance: patient tolerated the procedure well with no immediate complications Comments: Findings: Exaggerated grade 2 cystocele likely secondary to conscious sedation. Two right angle retractors were inserted. Ring forceps were used to identify tail end of Monodek suture. This was elevated to cut one side of the knot to loosen the sacrospinous ligament suspension. A small piece of Monodek suture remained incorporated in the vaginal tissue. Multiple attempts were performed to retrieve suture without success. Decision was made to leave in place as this material is absorbable. Hemostasis was achieved with running lock of 0-Vicryl at the right vaginal apex. Patient tolerated procedure well. I did confirm w/ the doctor It was not a mesh that was removed nor a sling. The sacrospinous ligament suspension was done by utilizing a Monodek suture that tied the right vaginal apex to the sacrospinous ligament so essentially, she says she only removed with one singular suture. I was leaning towards using 53899 or an E/M code, with a modifier 78, as CPT code 57282 and 57260 was billed prior to this procedure, which is best suitable? Thank you all so very much!

 

[nielynco]

Hello OB/GYN Coders,

Need your assistance with the CPT code for this procedure performed in the office please:

Date/Time:0:00 AM Performed by: Dr Who; Verbal consent obtained. Written consent obtained. Risks and benefits: risks, benefits and alternatives were discussed Consent given by: patient Patient understanding: patient states understanding of the procedure being performed Patient consent: the patient's understanding of the procedure matches consent given Procedure consent: procedure consent matches procedure scheduled Relevant documents: relevant documents present and verified Patient identity confirmed: verbally with patient Time out: Immediately prior to procedure a "time out" was called to verify the correct patient, procedure, equipment, support staff and site/side marked as required. Local anesthesia used: yes Anesthesia: local infiltration Anesthesia :Local anesthesia used: yes Local Anesthetic: lidocaine 2% without epinephrine Anesthetic total: 5 mL Sedation patient sedated: yes Sedation type: moderate (conscious) sedation Sedatives: see MAR for details Analgesia: see MAR for details Vitals: Vital signs were monitored during sedation. Patient tolerance: patient tolerated the procedure well with no immediate complications Comments: Findings: Exaggerated grade 2 cystocele likely secondary to conscious sedation. Two right angle retractors were inserted. Ring forceps were used to identify tail end of Monodek suture. This was elevated to cut one side of the knot to loosen the sacrospinous ligament suspension. A small piece of Monodek suture remained incorporated in the vaginal tissue. Multiple attempts were performed to retrieve suture without success. Decision was made to leave in place as this material is absorbable. Hemostasis was achieved with running lock of 0-Vicryl at the right vaginal apex. Patient tolerated procedure well. I did confirm w/ the doctor It was not a mesh that was removed nor a sling. The sacrospinous ligament suspension was done by utilizing a Monodek suture that tied the right vaginal apex to the sacrospinous ligament so essentially, she says she only removed with one singular suture. I was leaning towards using 53899 or an E/M code, with a modifier 78, as CPT code 57282 and 57260 was billed prior to this procedure, which is best suitable? Thank you all so very much!

I would code 58999 and compare the work to 57100 for this procedure. The work is comparable to a vaginal biopsy. 53899 would not be correct as the suture was removed from the vaginal wall area, not the urinary tract system.

 

[dmarshall]

I would code 58999 and compare the work to 57100 for this procedure. The work is comparable to a vaginal biopsy. 53899 would not be correct as the suture was removed from the vaginal wall area, not the urinary tract system.

Got it! Thank you Melanie!