Korbc
Expert
hey guys
this excerpt of a surgery came through the system from the doc to me as a perineoplasty but i don't think it qualifies from what I'm reading as the description in the optum obgyn companion. I was thinking code from the integumentary excision for the tissue genitalia then repair code and a separate code for the I&D of the cyst? she also removed the varicose vein as well though. Kind of a weird one. Do you think the cyst is deep enough I could consider using 57135?
thanks!
see below
Patient confirmed the area of pain and unsatisfactory scar, which is at 4:00 of vagina at the level of the hymenal ring. There was 1 cm vaginal tissue protrusion in oval shape, tender of palpation.
After anesthesia was given, she was repositioned in dorsolithotomy position in Allen stirrups. Timeout was performed to confirm correct patient and correct procedure. Exam under anesthesia was performed. After that, the patient was prepped and draped in usual sterile fashion. Local anesthesia was given by injecting 0.5% Marcaine mixed with epinephrine in vaginal tissue around the protrusion tissue. An incision was made 1 mm from the border of the area. It turned out that there was a cyst that contained yellowish fatty liquid and a varicose vein adjacent to the cyst under that protrusion area. They were removed and sent to pathology. The vaginal scar was then repaired with 3.0 vicryl in usual sterile fashion. Some bleeder was cauterized with Bovie. Some interrupted stitches were also placed for hemostasis. Excellent hemostasis was observed at the conclusion of the case.
this excerpt of a surgery came through the system from the doc to me as a perineoplasty but i don't think it qualifies from what I'm reading as the description in the optum obgyn companion. I was thinking code from the integumentary excision for the tissue genitalia then repair code and a separate code for the I&D of the cyst? she also removed the varicose vein as well though. Kind of a weird one. Do you think the cyst is deep enough I could consider using 57135?
thanks!
see below
Patient confirmed the area of pain and unsatisfactory scar, which is at 4:00 of vagina at the level of the hymenal ring. There was 1 cm vaginal tissue protrusion in oval shape, tender of palpation.
After anesthesia was given, she was repositioned in dorsolithotomy position in Allen stirrups. Timeout was performed to confirm correct patient and correct procedure. Exam under anesthesia was performed. After that, the patient was prepped and draped in usual sterile fashion. Local anesthesia was given by injecting 0.5% Marcaine mixed with epinephrine in vaginal tissue around the protrusion tissue. An incision was made 1 mm from the border of the area. It turned out that there was a cyst that contained yellowish fatty liquid and a varicose vein adjacent to the cyst under that protrusion area. They were removed and sent to pathology. The vaginal scar was then repaired with 3.0 vicryl in usual sterile fashion. Some bleeder was cauterized with Bovie. Some interrupted stitches were also placed for hemostasis. Excellent hemostasis was observed at the conclusion of the case.
