CODING SNAPSHOT

PRE-OPERATIVE DIAGNOSIS: Large left ovarian complex cyst, 15 weeks gestation for G2P1.

POST-OPERATIVE DIAGNOSIS:   Same

OPERATION: Exploratory laparotomy, left oophorectomy, pelvic washings.

ANESTHESIA: Spinal

GROSS FINDINGS: Upon entering the abdomen, there was a 15-week sized uterus. There was one mild omental adhesion to the front of the uterus. The left ovary was smooth, nonadherent, in the cul-de-sac approximately 10 to 12 cm in size. It appeared to be predominantly cystic. The right ovary was normal in size, shape, and contour. No other pelvic pathology noted.

OPERATIVE PROCEDURE: After adequate spinal anesthesia, the patient was frog-legged. The Foley catheter was inserted. Patient was placed in a dorsal supine position. The abdominal area was prepped with Betadine. It was aseptically draped. A midline vertical incision was made, carried through the peritoneum, peritoneum elevated with two straights, entered carefully with a scalpel. Pelvic washings were performed. The left ovary was delivered through the incision. A clamp was placed across the infundibulopelvic ligament. A window was placed. A second clamp was placed over the infundibulopelvic ligament. The ovary was excised. It was sent for frozen section and returned as benign. The infundibulopelvic ligament was suture ligated with chromic and #1 Vicryl. Good hemostasis was noted. All sponge, needle and instrument counts were correct. The peritoneum was reapproximated with a running suture of 0-PDS. The skin was reapproximated with a staple gun and interrupted 4-0 Rapide sutures. Estimated blood loss 10cc. Patient was taken to the recovery room in satisfactory condition. Fetal heart tones were noted in the recovery room.

ICD-10-CM Code(s):

O34.82 Maternal care for other abnormalities of pelvic organs, second trimester
N83.20 Cyst, ovarian
Z3A.15 15 weeks gestation of pregnancy

Rationale:   Chapter 15 Guidelines (C.15.a.1) state all conditions are assumed to complicate the pregnancy unless documented otherwise.  In this case, left oophorectomy is performed for ovarian cyst and patient is stated as pregnant.  The encounter for maternal care as a pregnancy complication is based on the site of the condition and codes are specific to cervix, uterus, vagina, vulva/perineum, and other specified.   A second code is added to identify the abnormality.

In ICD-10-CM the final character for Chapter 15 is determined by the trimester (C.15.A.3) 15 weeks is second trimester and “2” would be assigned.

1st trimester     less than 14 weeks
2nd trimester    14 weeks 0 days to less than 28 weeks
3rd trimester    28 weeks to delivery

Instructional note at the beginning of Chapter 15 states to code the week of gestation to identify the specific week of the pregnancy.

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