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I need some assistance with coding this procedure: this is what I have so far
37617 - 59
58545-51
58662- 51
However for the aspiration and excision of the cyst I am leaning for 49322
Post-operative Diagnosis: same as preop diagnosis
1. Robotic Assisted Laparoscopic Myomectomy with contained tissue extraction
2. Chromopertubation
Pre-operative Diagnosis: Uterine leiomyoma, unspecified location [D25.9],Bulky or enlarged uterus [N85.2]
Post-operative Diagnosis: same
Anesthesia Type: General Anesthesia
Findings:
1. Laparoscopic entry showed no evidence of blunt or sharp trauma
2. Uterus was 16 week size, globular with large left fibroid
3. Right Adnexa & Ovarian Fossa: Right ovary w/ endoetrioma
4. Left Adnexa & Ovarian Fossa: Left ovarian hemorrhagic cyst and tube wnl
5. Anterior Cul de Sac: wnl
6. Posterior Cul de Sac: wnl
7. Appendix wnl
Procedure in Detail:
The patient was taken to the operating room where general anesthesia was administered and found to be adequate. She was placed in the Allen stirrups, prepped and draped in the usual sterile fashion. The uterus was sounded to 10cm and a RUMI was placed. Foley was placed. Attention was then turned to the abdomen for entry
Abdominal Entry
Infiltration of 0.5% marcaine local anesthetic was injected and a linear incision was made at the base of the patient's umbilicus. Open entry technique was performed without difficulty and entry into the abdominal cavity was performed. A Small Alexis gel pointwas placed inside this 3 cm incision and the gel-port device was applied and insufflation was established. 2 x 8 mm trocars were placed in the right and 1x left lower quadrants under direct visualization.
The abdomen and pelvis were then examined laparoscopically and the above findings were noted. The patient was then placed in steep trendelenburg.
The Da Vinci Xi was docked without any complications. The pressure was decreased to 15 mmHg
Findings were as noted above
Ovarian cystectomy
The right ovary had a large endometrioma on it. This was aspirated and the base of the cyst was excised.
Bull Dog Clip Placement
The retroperitoneum was opened medial approach bilaterally. The Ureter was identified and the UA was noted to travel below the UA. Bilaterally the UA were clipped reversibly with the bull dog clips.
2x Bull dog clips were also placed on the utero-ovarian.
These were both removed at the end of the procedure.
Myomectomy
The connection between the fibroid and the fundus of the uterus was noted to be approx 3 cm. This was injected with 10 cc Vasopressin (diluted 20 U/100cc NS). Monopolar scissors were used to make an incision on the serosa and dissect until the capsule of the fibroid was visualized. Once the serosa was completely taken down the single tooth tenaculum was used to grasp the fibroid and the fibroid was separated from the surrounding myometrium in a circumferential fashion. This fibroid was removed directly from the umbilical incision.
Attention was then brought to the left broad ligment fibroid, this is approximately 7cm in side. This was injected with 10 cc Vasopressin (diluted 20 U/100cc NS). Monopolar scissors were used to make an incision on the serosa and dissect until the capsule of the fibroid was visualized. Once the serosa was completely taken down the single tooth tenaculum was used to grasp the fibroid and the fibroid was separated from the surrounding myometrium in a circumferential fashion.Once the fibroid was separated from the uterus it was placed in the RUQ.
Of both incision, the myometrium was re-approximated using 2-0 V- loc suture in a running fashion in 3 separate layers. The serosal layer was re-approximated using a 2-0 V- loc using a baseball stitch. Remaining exposed edges were brought together with 2-0 monocryl.
Chromopertubation
Methylene blue tinged fluid was pushed through the RUMI , but due to overdilation, the methylene blue dye backflowed through the cervi only.
Extraction of specimen
The specimen was the placed in a laparoscopic bag.
Again the camera and robotic instruments were removed the bag was brought to the surface of the abdomen and tissue extraction was performed using a "coring"method with a scalpel. Once the specimen was removed laparoscopy was performed to remove any remaining clots and hemostasis of the abdomen was noted.
Hemostasis was noted over the suture line and Tisseel hemostatic agent was placed and allowed to dry over this area. Trocars were removed under direct visualization.
The fascia at the umbilical incision was closed with 0-vicryl. The skin incisions were then re-approximated with 4-0 monocryl. Sponge, lap, needle and instrument counts were counts were correct x 2. The patient tolerated the procedure well and was taken to the recovery room awake and in stable condition
I need some assistance with coding this procedure: this is what I have so far
37617 - 59
58545-51
58662- 51
However for the aspiration and excision of the cyst I am leaning for 49322
Post-operative Diagnosis: same as preop diagnosis
1. Robotic Assisted Laparoscopic Myomectomy with contained tissue extraction
2. Chromopertubation
Pre-operative Diagnosis: Uterine leiomyoma, unspecified location [D25.9],Bulky or enlarged uterus [N85.2]
Post-operative Diagnosis: same
Anesthesia Type: General Anesthesia
Findings:
1. Laparoscopic entry showed no evidence of blunt or sharp trauma
2. Uterus was 16 week size, globular with large left fibroid
3. Right Adnexa & Ovarian Fossa: Right ovary w/ endoetrioma
4. Left Adnexa & Ovarian Fossa: Left ovarian hemorrhagic cyst and tube wnl
5. Anterior Cul de Sac: wnl
6. Posterior Cul de Sac: wnl
7. Appendix wnl
Procedure in Detail:
The patient was taken to the operating room where general anesthesia was administered and found to be adequate. She was placed in the Allen stirrups, prepped and draped in the usual sterile fashion. The uterus was sounded to 10cm and a RUMI was placed. Foley was placed. Attention was then turned to the abdomen for entry
Abdominal Entry
Infiltration of 0.5% marcaine local anesthetic was injected and a linear incision was made at the base of the patient's umbilicus. Open entry technique was performed without difficulty and entry into the abdominal cavity was performed. A Small Alexis gel pointwas placed inside this 3 cm incision and the gel-port device was applied and insufflation was established. 2 x 8 mm trocars were placed in the right and 1x left lower quadrants under direct visualization.
The abdomen and pelvis were then examined laparoscopically and the above findings were noted. The patient was then placed in steep trendelenburg.
The Da Vinci Xi was docked without any complications. The pressure was decreased to 15 mmHg
Findings were as noted above
Ovarian cystectomy
The right ovary had a large endometrioma on it. This was aspirated and the base of the cyst was excised.
Bull Dog Clip Placement
The retroperitoneum was opened medial approach bilaterally. The Ureter was identified and the UA was noted to travel below the UA. Bilaterally the UA were clipped reversibly with the bull dog clips.
2x Bull dog clips were also placed on the utero-ovarian.
These were both removed at the end of the procedure.
Myomectomy
The connection between the fibroid and the fundus of the uterus was noted to be approx 3 cm. This was injected with 10 cc Vasopressin (diluted 20 U/100cc NS). Monopolar scissors were used to make an incision on the serosa and dissect until the capsule of the fibroid was visualized. Once the serosa was completely taken down the single tooth tenaculum was used to grasp the fibroid and the fibroid was separated from the surrounding myometrium in a circumferential fashion. This fibroid was removed directly from the umbilical incision.
Attention was then brought to the left broad ligment fibroid, this is approximately 7cm in side. This was injected with 10 cc Vasopressin (diluted 20 U/100cc NS). Monopolar scissors were used to make an incision on the serosa and dissect until the capsule of the fibroid was visualized. Once the serosa was completely taken down the single tooth tenaculum was used to grasp the fibroid and the fibroid was separated from the surrounding myometrium in a circumferential fashion.Once the fibroid was separated from the uterus it was placed in the RUQ.
Of both incision, the myometrium was re-approximated using 2-0 V- loc suture in a running fashion in 3 separate layers. The serosal layer was re-approximated using a 2-0 V- loc using a baseball stitch. Remaining exposed edges were brought together with 2-0 monocryl.
Chromopertubation
Methylene blue tinged fluid was pushed through the RUMI , but due to overdilation, the methylene blue dye backflowed through the cervi only.
Extraction of specimen
The specimen was the placed in a laparoscopic bag.
Again the camera and robotic instruments were removed the bag was brought to the surface of the abdomen and tissue extraction was performed using a "coring"method with a scalpel. Once the specimen was removed laparoscopy was performed to remove any remaining clots and hemostasis of the abdomen was noted.
Hemostasis was noted over the suture line and Tisseel hemostatic agent was placed and allowed to dry over this area. Trocars were removed under direct visualization.
The fascia at the umbilical incision was closed with 0-vicryl. The skin incisions were then re-approximated with 4-0 monocryl. Sponge, lap, needle and instrument counts were counts were correct x 2. The patient tolerated the procedure well and was taken to the recovery room awake and in stable condition