Case # 16 clinical added to Answer key & Rationale
Case # 16 clinical added to Answer key & Rationale
Since the clinical info wasn't included in posting of answer & rationale; and the link to case clinical info given now is not accessible (error page shows up) .... I thought it wise to include the missing clinical info.
See below for the answer key and rationale.
ANSWER KEY
CPT: 58554
CPT Modifiers: none
ICD-9: 621.30
RATIONALE
The provider performs a laparoscopic-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy. The codes for hysterectomy are selected based on approach and weight of the uterus which is 260 g in this case. The postoperative diagnoses documented include endometrial hyperplasia and postmenopausal bleeding. According to the Official Coding Guidelines, do not report codes for signs and symptoms when a definitive diagnosis is determined. Postmenopausal bleeding is a symptom of endometrial hyperplasia. The only diagnosis code reported is endometrial hyperplasia.
CPT: 58554
Steps to look up: Hysterectomy/Vaginal
ICD-9-CM: 621.30
Steps to look up: Hyperplasia, hyperplastic/endometrium, endometrial
Hint: Case 16 in another operative report and involves a hysterectomy.
Case #16
ANESTHESIA PERFORMED: General
PREOPERATIVE DIAGNOSES: Endometrial hyperplasia, postmenopausal bleeding
POSTOPERATIVE DIAGNOSIS: Endometrial hyperplasia, postmenopausal bleeding
PROCEDURE PERFORMED: Laparoscopic-assisted vaginal hysterectomy (LAVH), bilateral salpingooophorectomy (BSO).
COMPLICATIONS: None
ESTIMATED BLOOD LOSS: 50 cc
URINE OUTPUT: 100 cc
FLUID: 1200 cc of crystalloid
Uterus: 260 g
FINDINGS: Normal-appearing uterus and ovaries bilaterally
INDICATIONS FOR PROCEDURE: The patient is a 76-year-old gravida 3, para 3, who has had on and off postmenopausal bleeding for a number of years. She has had office and endometrial biopsies as well as hysteroscopy, D and C with recurrence of postmenopausal bleeding this time and a thickened lining of 1 cm. The patient elected to proceed with definitive surgical management. She was counseled extensively on risks, benefits, alternatives to laparoscopic-assisted vaginal hysterectomy with bilateral salpingooophorectomy and signed consent.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was found to be adequate. She was prepped and draped in a normal sterile fashion. Legs were placed in Allen stirrups, and a Foley catheter was inserted. Attention was first turned vaginally where a speculum was inserted and a uterine manipulator placed. Attention was then turned abdominally where a 5-mm infraumbilical incision was made using a scalpel. Using the Visiport, the scope and port were introduced under direct visualization into the peritoneal cavity. Peritoneum was then insufflated with CO2 gas to approximately 30 mmHg pressure. The abdomen was transiluminated in the left lower quadrant. A 5-mm incision was made and a 5-mm Apple port placed again under direct visualization. This was repeated on the right side. Attention was first turned to the right IP ligament. It was isolated and tented using the Allis clamp and transected using the Harmonic Scalpel. The round ligament was similarly identified and isolated and transected using the Harmonic Scalpel. The anterior portion on the right of the bladder flap was then created using the Harmonic Scalpel. Attention was then turned to the left where similarly using an Allis clamp, the IP ligament was isolated and tented. The Harmonic scalpel was used for cautery and transection. The round ligament was then isolated and again using the Harmonic, transected. Remainder of the bladder flap was then created using the Harmonic Scalpel. All pedicles were then inspected and found to be hemostatic. Attention was then turned vaginally where the weighted speculum was inserted. The cervix was grasped with a Jacobs retractor and circumscribed using the Bovie cautery. Posterior aspect of the vaginal area was then grasped and the posterior peritoneum posteriorly. Anteriorly, the peritoneum was the identified. Two Heaney clamps were used at either angle of the uterosacral ligaments and transected using Mayo scissors, sutured using 0 Vicryl. At this time, the anterior peritoneum was entered under direct visualization. Two additional bites on the right and the left using the Heaney clamp to the uterine arteries up to the broad ligament, were then placed on either side, transected using Mayo scissors and sutured using 0 Vicryl. At this point, the area of the laparoscopic dissection was obtained. A final Heaney clamp was placed at the right angle, transected using Mayo scissors, and sutured using 0 Vicryl. The entire uterus, tubes, and ovaries were then removed vaginally. Pedicles were inspected vaginally and found to be hemostatic. The peritoneum was grasped anteriorly and then the cuff closed in a running locked fashion using a 0 Vicrylsuture. Final inspection of the vaginal cuff showed hemostasis.
Attention was then turned abdominally where the vaginal cuff was inspected and irrigated with normal saline solution and again found to be hemostatic. Both ureters were identified and visualized until mobilization was seen. Final inspection of all pedicles demonstrated hemostasis. The ports were removed under direct visualization. Abdomen was then cleared of all CO2 gas. The skin incisions were closed using 4-0 Monocryl suture using Mastisol and Steri-Strips. The vaginal cuff was inspected one final time and found to be hemostatic. All sponge, lap, and needle counts were correct x2, and the patient was transferred to recovery room in stable condition.
https://www.aapc.com/code/aapc-coding-challenge/cases.aspx