mass31
Contributor
wondering if anyone can tell me which code 59812 or 59820 should be used for this encounter :
PRE-OP DX- SPONTANEOUS 1ST TRIMEST MISCARRIAGE
POST-OP DX- SAME
PROCEDURE PERFORMED- DIALATION AND EVACUATION
HEAVY WEIGHTED SPECULUM WAS PLACED IN THE POSTERIOR ASPECT OF VAGINA AND SIMS RETRACTOR IN THE ANTERIOR ASPECT OF VAGINA. THE CERVIX WAS GRASPED WITH A SINGLE TOOTH TENACULUM AND THE BLADDER WAS THEN STRAIGHT CATCHED REMOVED APPROX 50 CC OF URINE. THE UTERUS WAS THEN GENTLY SOUNDED TO ABOUT 10CM AND THE CERVIX WAS THEN GENTLY DILATED WITH HEGAR DILATORS UP TO A 15X9 MM CANNULAE EVACUATION. CANNULAE WAS THEN GENTLY PLACED INTO THE UTERUS AND SUCTION WAS APPLIED GENTLY AND EVACUATION WAS PERFORMED WITH PRODUCTS OF CONCEPTION NOTED IN THE COLLECTION BAG. THE EVACUATION COUNT WAS THEN REMOVED AND USING A CURETTAGE THE UTERUS WAS GENTLY CURETTAGE. ONE MORE PASS WITH THE EVACUATOR WAS PERFORMED AND ONE MORE PASS WITH THE CURETTAGE UNTIL THE UTERINE WALL WAS NOTED TO BE GRITTY. THERE WAS MINIMAL BLEEDING. THE SINGLE TOOTH TENACULUM AND INSTRUMENT COUNTS CORRECT AND THE PATIENT WAS TAKEN TO RECOVERY IN STABLE CONDITION.
PRE-OP DX- SPONTANEOUS 1ST TRIMEST MISCARRIAGE
POST-OP DX- SAME
PROCEDURE PERFORMED- DIALATION AND EVACUATION
HEAVY WEIGHTED SPECULUM WAS PLACED IN THE POSTERIOR ASPECT OF VAGINA AND SIMS RETRACTOR IN THE ANTERIOR ASPECT OF VAGINA. THE CERVIX WAS GRASPED WITH A SINGLE TOOTH TENACULUM AND THE BLADDER WAS THEN STRAIGHT CATCHED REMOVED APPROX 50 CC OF URINE. THE UTERUS WAS THEN GENTLY SOUNDED TO ABOUT 10CM AND THE CERVIX WAS THEN GENTLY DILATED WITH HEGAR DILATORS UP TO A 15X9 MM CANNULAE EVACUATION. CANNULAE WAS THEN GENTLY PLACED INTO THE UTERUS AND SUCTION WAS APPLIED GENTLY AND EVACUATION WAS PERFORMED WITH PRODUCTS OF CONCEPTION NOTED IN THE COLLECTION BAG. THE EVACUATION COUNT WAS THEN REMOVED AND USING A CURETTAGE THE UTERUS WAS GENTLY CURETTAGE. ONE MORE PASS WITH THE EVACUATOR WAS PERFORMED AND ONE MORE PASS WITH THE CURETTAGE UNTIL THE UTERINE WALL WAS NOTED TO BE GRITTY. THERE WAS MINIMAL BLEEDING. THE SINGLE TOOTH TENACULUM AND INSTRUMENT COUNTS CORRECT AND THE PATIENT WAS TAKEN TO RECOVERY IN STABLE CONDITION.