Patient was scheduled for IUD removal with hysteroscope, surgical: with removal of foreign body. As seen below in operative report " During dilation retained segment of the IUD fell out of the cervix and was sent to pathology. The Hysteroscope was inserted a general survey of the uterine cavity was noted to be normal without any other retained portion of the device. Would this still be coded as 58562 with modifier 52.
Findings: Fragment of paragard iud removed
Procedure Details:
The patient was seen in the preoperative area. The risks, benefits, complications, treatment options, non-operative alternatives, expected recovery and outcomes were discussed with the patient. The possibilities of reaction to medication, pulmonary aspiration, injury to surrounding structures, bleeding, recurrent infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The site of surgery was properly noted/marked if necessary. The patient was actively warmed in the preoperative area. Preoperative antibiotics are not indicated.. Venous thrombosis prophylaxis are not indicated.
Patient was seen and examined and consented in the preoperative holding area.
And was taken to the operating room where she was placed under general anesthesia.
Prepped and draped in the normal sterile fashion in the dorsolithotomy position in Allen stirrups.
Preoperative timeout was performed.
Weighted speculum was placed into the vagina.
Anterior lip of the cervix was grasped with a single-tooth tenaculum.
The cervix was dilated to 25 French.
During dilation retained segment of the IUD fell out of the cervix and was sent to pathology for gross examination.
Hysteroscope was inserted a general survey of the uterine cavity was noted to be normal without any other retained portion of the device.
Hysteroscope was removed.
Single-tooth tenaculum was removed.
Weighted speculum was removed.
The patient tolerated the procedure well and was taken to the postoperative recovery room in stable condition.
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Cancer Staging: no
Findings: Fragment of paragard iud removed
Procedure Details:
The patient was seen in the preoperative area. The risks, benefits, complications, treatment options, non-operative alternatives, expected recovery and outcomes were discussed with the patient. The possibilities of reaction to medication, pulmonary aspiration, injury to surrounding structures, bleeding, recurrent infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The site of surgery was properly noted/marked if necessary. The patient was actively warmed in the preoperative area. Preoperative antibiotics are not indicated.. Venous thrombosis prophylaxis are not indicated.
Patient was seen and examined and consented in the preoperative holding area.
And was taken to the operating room where she was placed under general anesthesia.
Prepped and draped in the normal sterile fashion in the dorsolithotomy position in Allen stirrups.
Preoperative timeout was performed.
Weighted speculum was placed into the vagina.
Anterior lip of the cervix was grasped with a single-tooth tenaculum.
The cervix was dilated to 25 French.
During dilation retained segment of the IUD fell out of the cervix and was sent to pathology for gross examination.
Hysteroscope was inserted a general survey of the uterine cavity was noted to be normal without any other retained portion of the device.
Hysteroscope was removed.
Single-tooth tenaculum was removed.
Weighted speculum was removed.
The patient tolerated the procedure well and was taken to the postoperative recovery room in stable condition.
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Cancer Staging: no