tdesher
Networker
I do the billing for an ASC and the office is billing conflicting codes, I bill from the op report they just bill what the Dr says she did. I am not sure if I should be coding 15839 or 12031 & 11421 for the "Labiaplasty and repair"
POSTOPERATIVE DIAGNOSES:
1. Right labial cyst and labial tear.
2. Stress urinary incontinence.
3. Interstitial cystitis with microscopic hematuria.
4. Rectocele.
5. Urinary frequency.
PROCEDURES PERFORMED:
1. Midurethral sling (Altis).
2. Cystoscopy with calibration.
3. Rectocele repair.
4. Right labial cyst excision.
5. Labiaplasty.
6. Repair of lacerated labia and hypertrophy.
PREOPERATIVE ANTIBIOTICS: Two grams of Ancef IV.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where anesthesia was found to be adequate. She was prepped and draped in the normal sterile fashion and placed in the dorsal lithotomy position with her legs carefully placed in Allen boot stirrups. Care was taken to avoid excessive flexion or extension of the hip or knee joints. A Foley catheter was then inserted and clamped and placed on the drape.
Altis sling:
Attention was then turned to suburethral area where local infiltration of 0.25% Marcaine solution with epinephrine with 1:100,000 epinephrine was injected with saline was performed at the level of the mid urethra. This was then extended into the lateral sulci of the distal vagina towards the obturator and internus muscle. The vaginal mucosa was then grasped with two Allis clamps and a midline vertical incision at the level of the midurethra was made using a scalpel. Using a Metzenbaum scissors periurethral tunnels were then made at 45-degree angle from midline beneath the inferior pubic ramus bilaterally just to the level of the ramus and obturator internus muscle region. The Altis sling was then brought on to the field. It was loaded appropriately on to the right trocar. The trocar was then inserted in a cephalad direction and then with a twist of the handle the tip of the device was guided behind the inferior pubic ramus into the obturator internus muscle and membrane. The Helical passer was then removed in the same way it was placed dislodging the right fixation tip of the sling. The left fixation tip was then guided into place on to the left Helical passing trocar and was placed in the same fashion on the patient's left side. At this point, cystoscopy was then performed with 200 mL of sterile water left in the bladder with the above findings noted. The scope was then removed using Crede maneuver. Leakage of urine was seen from the urethra. Sling tensioning device was then tensioned slightly until no leakage was seen from urethra and appropriate placement of sling was noted under the urethra without too much tension. The tensioning suture was then cut under direct visualization. The vaginal mucosa was then closed with 2-0 Vicryl in a running locked fashion.
Cystoscopy with calibration was performed with the above findings noted. No abnormalities were seen. Crede testing was negative at 200 mL in the bladder.
Rectocele repair:
Attention was then turned to the rectocele repair. Three Allis clamps were placed on the vaginal mucosa and introitus and a diamond-shaped skin incision was then made using a Bovie proceeding from the posterior fourchette to the perineum. The overlying skin was then removed en bloc using Bovie on cut mode. Hemostasis was obtained as needed using Bovie as well coagulation. With concomitant rectal exam moving the rectum away from the dissection plane, the rectovaginal space was entered sharply using Metzenbaum scissors. The incision was then extended apically using the Bovie. The rectovaginal space was dissected further with sharp and blunt dissection technique. The rectal muscularis was then plicated using 2-0 Vicryl suture in a running fashion parallel to the rectal direction with concomitant rectal exam assuring that the rectal mucosa was intact. This was tied at the perineal level. The vaginal mucosa was then turned as needed using the Bovie and then reapproximated with 2-0 Vicryl suture in a running locked fashion, 0-Vicryl was also used to reapproximate the bulbocavernosus muscles in two U-type stitch placement. The perineum was then closed subcutaneously with subcuticular 2-0 Vicryl.
Attention was then turned to the right labia. A 1- to 2-cm cyst was noted in the upper labial area approximately 2 cm inferior to the clitoral region. This was incised with the scalpel and the cyst was then removed using the Metzenbaum scissors taking care to shell this out. During removal, it was punctured and clear fluid was noted to be extravasating. Specimen was sent to Pathology. The right labial tear was noted just inferior to this portion separating in the upper from or labia minora. The lower part of the labia minora was then excised due to the hypertrophy appeared to the left side, and then the inferior to superior aspects were stitched together using 4-0 Vicryl suture in a combination of simple interrupted and mattress type sutures. The lower aspect of the labia was then reapproximated after obtaining hemostasis using the needle-tip Bovie in the same areas 4-0 Vicryl. Excellent hemostasis was obtained. Some minor swelling was noted by the end of the case. Ice pack was applied to the perineum and local infiltration was performed with Marcaine solution with epinephrine.
The patient tolerated all procedures well. All sponge, lap, and needle counts were correct x2. A Foley was removed, and she was taken to Recovery for voiding trial.
POSTOPERATIVE DIAGNOSES:
1. Right labial cyst and labial tear.
2. Stress urinary incontinence.
3. Interstitial cystitis with microscopic hematuria.
4. Rectocele.
5. Urinary frequency.
PROCEDURES PERFORMED:
1. Midurethral sling (Altis).
2. Cystoscopy with calibration.
3. Rectocele repair.
4. Right labial cyst excision.
5. Labiaplasty.
6. Repair of lacerated labia and hypertrophy.
PREOPERATIVE ANTIBIOTICS: Two grams of Ancef IV.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where anesthesia was found to be adequate. She was prepped and draped in the normal sterile fashion and placed in the dorsal lithotomy position with her legs carefully placed in Allen boot stirrups. Care was taken to avoid excessive flexion or extension of the hip or knee joints. A Foley catheter was then inserted and clamped and placed on the drape.
Altis sling:
Attention was then turned to suburethral area where local infiltration of 0.25% Marcaine solution with epinephrine with 1:100,000 epinephrine was injected with saline was performed at the level of the mid urethra. This was then extended into the lateral sulci of the distal vagina towards the obturator and internus muscle. The vaginal mucosa was then grasped with two Allis clamps and a midline vertical incision at the level of the midurethra was made using a scalpel. Using a Metzenbaum scissors periurethral tunnels were then made at 45-degree angle from midline beneath the inferior pubic ramus bilaterally just to the level of the ramus and obturator internus muscle region. The Altis sling was then brought on to the field. It was loaded appropriately on to the right trocar. The trocar was then inserted in a cephalad direction and then with a twist of the handle the tip of the device was guided behind the inferior pubic ramus into the obturator internus muscle and membrane. The Helical passer was then removed in the same way it was placed dislodging the right fixation tip of the sling. The left fixation tip was then guided into place on to the left Helical passing trocar and was placed in the same fashion on the patient's left side. At this point, cystoscopy was then performed with 200 mL of sterile water left in the bladder with the above findings noted. The scope was then removed using Crede maneuver. Leakage of urine was seen from the urethra. Sling tensioning device was then tensioned slightly until no leakage was seen from urethra and appropriate placement of sling was noted under the urethra without too much tension. The tensioning suture was then cut under direct visualization. The vaginal mucosa was then closed with 2-0 Vicryl in a running locked fashion.
Cystoscopy with calibration was performed with the above findings noted. No abnormalities were seen. Crede testing was negative at 200 mL in the bladder.
Rectocele repair:
Attention was then turned to the rectocele repair. Three Allis clamps were placed on the vaginal mucosa and introitus and a diamond-shaped skin incision was then made using a Bovie proceeding from the posterior fourchette to the perineum. The overlying skin was then removed en bloc using Bovie on cut mode. Hemostasis was obtained as needed using Bovie as well coagulation. With concomitant rectal exam moving the rectum away from the dissection plane, the rectovaginal space was entered sharply using Metzenbaum scissors. The incision was then extended apically using the Bovie. The rectovaginal space was dissected further with sharp and blunt dissection technique. The rectal muscularis was then plicated using 2-0 Vicryl suture in a running fashion parallel to the rectal direction with concomitant rectal exam assuring that the rectal mucosa was intact. This was tied at the perineal level. The vaginal mucosa was then turned as needed using the Bovie and then reapproximated with 2-0 Vicryl suture in a running locked fashion, 0-Vicryl was also used to reapproximate the bulbocavernosus muscles in two U-type stitch placement. The perineum was then closed subcutaneously with subcuticular 2-0 Vicryl.
Attention was then turned to the right labia. A 1- to 2-cm cyst was noted in the upper labial area approximately 2 cm inferior to the clitoral region. This was incised with the scalpel and the cyst was then removed using the Metzenbaum scissors taking care to shell this out. During removal, it was punctured and clear fluid was noted to be extravasating. Specimen was sent to Pathology. The right labial tear was noted just inferior to this portion separating in the upper from or labia minora. The lower part of the labia minora was then excised due to the hypertrophy appeared to the left side, and then the inferior to superior aspects were stitched together using 4-0 Vicryl suture in a combination of simple interrupted and mattress type sutures. The lower aspect of the labia was then reapproximated after obtaining hemostasis using the needle-tip Bovie in the same areas 4-0 Vicryl. Excellent hemostasis was obtained. Some minor swelling was noted by the end of the case. Ice pack was applied to the perineum and local infiltration was performed with Marcaine solution with epinephrine.
The patient tolerated all procedures well. All sponge, lap, and needle counts were correct x2. A Foley was removed, and she was taken to Recovery for voiding trial.