rockylopez
Networker
Hello fellow coders. I wanted to ask for anyone's input if i am coding this surgery correctly.
CPT code 58800 & 58661,RT???
Pre-procedure diagnosis:
Adnexal mass 27 cm
Post-procedure diagnosis:
right adnexal mass, filled with clear fluid, 3750 cc
Procedures performed:
Dx. L/S. drainage of ovarian cyst and RSO
Technique/Procedure:
Specimens removed/altered: right tube and ovary
Implant(s): none
Fluids:
700 cc
Urine output:
150 cc
Approach: laparoscopic
The patient was taken to the operating room and placed under general anesthesia and prepped and draped in the dorsal lithotomy position. Her bladder was drained with a foley catheter and a sponge stick placed in the vagina. The upper abdomen beneath the xyphoid was injected with local anesthetic and the 5 mm incision made. The Veress needle was inserted and easy saline flow and low intrabdominal pressure confirmed. The abdomen was insufflated and once appropriate pressures obtained the Veress needle was removed and the 5mm trocar inserted. The camera was inserted and entered the perioneal cavity. Attention was turned to the right upper quadrant and local anesthesia was infiltrated. The 12 mm incision was made and the 12 mm trocar and sleeve were advanced into the abdomen under direct visualization. The large mass filled the abdomen but a small space was visible anteriorly and on either gutter. The right sided 5 mm trocar was placed on the right lateral mid abdomen under direct visualization. Due to inability to visualize the the decision was made to drain the cyst. The needle tip cautery was used to incise the capsule and the suction irrigator inserted and drained of copious fluid. The cyst was manipulated to allow additional drainage of as much fluid as possible. The total amount of fluid from the cyst was 3750 cc. The gyrus device was now used to progressively cauterize and ligate the right uterine ovarian ligament and the blood supply to the ovary laterally. The large endocatch was now inserted and the grapers used to place the tube and ovary into the bag. This was brought up through the right sided port and the ovary progressively removed using kocher clamps. The bag was removed. There was good hemostasis noted from the pedicles. The Carter-Thompson device was used to close the 12 mm incision at the fascia. The instruments were removed and the abdomen desufflated. The skin was closed with monocryl Counts were correct x 2.
CPT code 58800 & 58661,RT???
Pre-procedure diagnosis:
Adnexal mass 27 cm
Post-procedure diagnosis:
right adnexal mass, filled with clear fluid, 3750 cc
Procedures performed:
Dx. L/S. drainage of ovarian cyst and RSO
Technique/Procedure:
Specimens removed/altered: right tube and ovary
Implant(s): none
Fluids:
700 cc
Urine output:
150 cc
Approach: laparoscopic
The patient was taken to the operating room and placed under general anesthesia and prepped and draped in the dorsal lithotomy position. Her bladder was drained with a foley catheter and a sponge stick placed in the vagina. The upper abdomen beneath the xyphoid was injected with local anesthetic and the 5 mm incision made. The Veress needle was inserted and easy saline flow and low intrabdominal pressure confirmed. The abdomen was insufflated and once appropriate pressures obtained the Veress needle was removed and the 5mm trocar inserted. The camera was inserted and entered the perioneal cavity. Attention was turned to the right upper quadrant and local anesthesia was infiltrated. The 12 mm incision was made and the 12 mm trocar and sleeve were advanced into the abdomen under direct visualization. The large mass filled the abdomen but a small space was visible anteriorly and on either gutter. The right sided 5 mm trocar was placed on the right lateral mid abdomen under direct visualization. Due to inability to visualize the the decision was made to drain the cyst. The needle tip cautery was used to incise the capsule and the suction irrigator inserted and drained of copious fluid. The cyst was manipulated to allow additional drainage of as much fluid as possible. The total amount of fluid from the cyst was 3750 cc. The gyrus device was now used to progressively cauterize and ligate the right uterine ovarian ligament and the blood supply to the ovary laterally. The large endocatch was now inserted and the grapers used to place the tube and ovary into the bag. This was brought up through the right sided port and the ovary progressively removed using kocher clamps. The bag was removed. There was good hemostasis noted from the pedicles. The Carter-Thompson device was used to close the 12 mm incision at the fascia. The instruments were removed and the abdomen desufflated. The skin was closed with monocryl Counts were correct x 2.