Wiki Diagnostic D and C

[duplicatesandra]

My physician performed a Diagnostic D&C on a patient with the

POSTOPERATIVE DIAGNOSIS(ES): "abnormally rising beta hCG, cannot rule out ectopic pregnancy".

SPECIMENS: Products of conception sent to Pathology for further evaluation.

SUMMARY:

The patient was taken to the operation room where she was prepped and draped in the normal sterile fashion. Anesthesia was found to be adequate anesthesia. Exam under anesthesia revealed a small, slightly anteverted uterus. A sterile speculum was inserted and the cervix was identified. A single-tooth tenaculum was applied to the anterior lip of the cervix. The cervix was cleansed with Betadine X2. A paracervical blcok with 5 mL of 1% Polocaine was perfomed at the 4 and 8 o'clock positions. The uterus was then gently sounded to approximatey 8 cm. The cervix was then dilated serially using Hegar dilatiors. An 8-Frnech suction catheter was inserted into the cervix and the uterus was cleared of all products of conception until no remaining products were noted. A sharp curette was then inserted through the cervix and again rotated circumferentilly until a gritty texture was noted in all quardrants. Suction curette was then reintrouduced to clear all remaining products and the single-tooth tenaculum was removed from the anterior lip of the cervix. Excellent hemostasis was noted at this time. All instruments were removed from the vagina. The patient tolerated the procedure well. She was transferred to the recovery room in stable condition.



My questions is do I use CPT code 59812? Can any one help me with this?

 

[ajs]

My physician performed a Diagnostic D&C on a patient with the

POSTOPERATIVE DIAGNOSIS(ES): "abnormally rising beta hCG, cannot rule out ectopic pregnancy".

SPECIMENS: Products of conception sent to Pathology for further evaluation.

SUMMARY:

The patient was taken to the operation room where she was prepped and draped in the normal sterile fashion. Anesthesia was found to be adequate anesthesia. Exam under anesthesia revealed a small, slightly anteverted uterus. A sterile speculum was inserted and the cervix was identified. A single-tooth tenaculum was applied to the anterior lip of the cervix. The cervix was cleansed with Betadine X2. A paracervical blcok with 5 mL of 1% Polocaine was perfomed at the 4 and 8 o'clock positions. The uterus was then gently sounded to approximatey 8 cm. The cervix was then dilated serially using Hegar dilatiors. An 8-Frnech suction catheter was inserted into the cervix and the uterus was cleared of all products of conception until no remaining products were noted. A sharp curette was then inserted through the cervix and again rotated circumferentilly until a gritty texture was noted in all quardrants. Suction curette was then reintrouduced to clear all remaining products and the single-tooth tenaculum was removed from the anterior lip of the cervix. Excellent hemostasis was noted at this time. All instruments were removed from the vagina. The patient tolerated the procedure well. She was transferred to the recovery room in stable condition.



My questions is do I use CPT code 59812? Can any one help me with this?

Yes since the trimester of pregnancy was not stated, you would use the 59812.