Good morning OB/Gyn Group,
I am asking for guidance regarding CPT codes for this return to surgery after Laps Total Hyst done on 12/06/23. Please see op note below;
Procedure: Diagnostic laparoscopy, vaginal exam under anesthesia, dense lysis of adhesions, vaginal cuff repair, small bowel serosal oversew, cystoscopy and laparotomy
Procedures Date: 12/23/2023
Pre-op Diagnosis:
Hemoperitoneum
Vaginal bleeding
Post-operative Diagnosis:
Partial 0.5cm full-thickness vaginal cuff dehiscence 2 cm medial from the left angle
complete peritoneal dehiscence of the vaginal cuff
Dense adhesions from the rectosigmoid to the vaginal cuff
Dense adhesions from the small bowel to the right ovary
500ml hemoperitoneum
Anesthesia: General
Drains: none
Findings: Vaginal exam showed a 0.5 cm hole 2 cm medial from the left angle. Friable right angle of the vaginal cuff with partial necrosis. Bleeding noted from raw peritoneal edge. Multiple dense adhesions of the bowel to the pelvic sidewall bilaterally and to the vaginal cuff. 500 mL coagulated hemoperitoneum. Ileum serosal tear 30 cm from the ileocecal valve. Normal-appearing appendix. Unremarkable spleen and liver.
Consults: video telemedicine general surgery consult for small bowel serosal tear
Estimated Blood Loss: 600ml. 500 mL of hemoperitoneum evacuated with 100 mL intraoperatively bleeding
Total IV Fluids: 3000ml
Urine output: 485ml. Clear
Complications: small bowel serosal tear during lysis of adhesions oversewen with 4 interrupted sutures of 3-0 PDS. Patient tolerated the procedure well.
Indication and Consent:
Patient presented to the hospital with vaginal bleeding and hemoperitoneum status post total laparoscopic hysterectomy the robotic.
Procedure Details
The patient was taken to the Operating Room with IV fluid running and SCDs placed on bilateral lower extremeties. Patient was identified as XXX and the procedure verified. A Time Out was held and the above information confirmed. 2 grams of Ancef given with 500mg of flagyl. A Foley was placed.
After induction of general anesthesia, the patient was placed in modified dorsal lithotomy position in Allen type stirrups where she was prepped, draped, and catheterized in the normal, sterile fashion. Vaginal cuff was visualized with a weighted speculum and a right angle. A small 0.5 cm hole was noted 2 cm medial to the left angle. Several 2-0 Vicryl pop-off's were used for primary mucosal repair of the vaginal cuff. There is also raw edges of peritoneum noted to be bleeding. Rectal exam was performed with no defects noted. Staff was notified to prepare for laparoscopic entry. All vaginal instruments were removed and the sponge stick was replaced inside of the vaginal canal.
Two towel clamps were applied to elevate the base of umbilicus. A vertical skin incision was made across the umbilical folds after skin was infiltrated with 1% lidocaine with epinephrine. The Veress needle was introduced into the peritoneal cavity at a straight angle without difficulty at the umbilicus. A saline drop test was performed to validate intraperitoneal placement. The pneumoperitoneum was established with CO2 gas to the pressure of 15 mm Hg. A 5 mm trocar was inserted into the abdomen. Intraabdominal placement was confirmed with laparoscope. Patient was then placed in trendelenburg position. A 5mm trocar was then advanced under direct visualization of the laparoscope supraumbilically. The pneumoperitoneum was established with CO2 gas to the pressure of 15 mm Hg. A 5 mm trocar was inserted in the right lower quadrant under direct laparoscopic visualization after skin was infiltrated as above with lidocaine. A 12 mm trocar was inserted to the right lower quadrant under direct laparoscopic visualization. Laparoscopic suction was used to aspirate most of the hemoperitoneum. There was a Seshan of the right and left sidewall as well as the cuff was compromised due to dense adhesions of bowel. Blunt dissection to remove the right sidewall adhesion to the small bowel was performed. Once separated, the right ovary was mobile enough to move to visualize any active bleeding. No active bleeding was noted after aspirations of clots. Attention was was placed to the left sidewall where no signs of bleeding was noted. The vaginal cuff was densely adhesed to the sigmoid colon. After several attempts to separate, it was decided to convert to laparotomy. Pneumoperitoneum was released and trocars were removed.
A midline incision was made suprapubic to inferior umbilicus with a scalpel. Monopolar was used to dissect down to the fascial layer. Dissection of the rectus off the fascia was performed. The fascial incision was then extended to the skin incision to maximize visualization. The peritoneum was entered and extended being careful to avoid any damage to adhesions. Wet laparotomy sponges were placed in the abdominal cavity. O'Sullivan-O'Connor Retractor was used to help retract with a bladder blade. The right ovary was visualized thoroughly inspected. Again, no active bleeding was noted. Attention was then placed to the Sigmoid to vaginal cuff adhesion. Sharp dissection was performed to help separate the adhesion. Once the Sigmoid colon was released it was noted that there was a complete peritoneal dehiscence of the vaginal cuff. 200 mL of saline was then backfilled into the bladder to help identify the margins. The bladder was then decompressed. The cuff angle STRATAFIX sutures were then identified and grasped with hemostats. The peritoneal edge was then grasped with Allis clamps. The vaginal cuff closure needed with figure-of-eight using 0 Vicryl pop-off's. Monopolar energy was used on the right areas around the peritoneal edge. After the vaginal cuff was closed, we ran the bowel to assess for injury during extensive lysis of adhesions. During this, approximately 30 cm proximal from the ileocecal valve there was a sub-centimeter area noted with superficial serosal abrasion which occurred at time of adhesiolysis. Intra-operative consult for general surgery was made. The on-call surgery attending was performing another surgery at another hospital and was unavailable for in-person assistance. The surgery resident was consulted into the OR to observe the serosal tear. The surgery resident FaceTime Dr. B and showed the serosal injury. Dr. A spoke with Dr. B via teleconference. Dr. B recommended oversewing the bowel. This was performed with four seromuscular interrupted 3-0 PDS sutures parallel to the long axis of the bowel so as not to narrow the bowel lumen as recommended. The bowel was then ran again from the ileocecal valve to the ligament of Treitz. Copious irrigation was used in the abdominal cavity throughout the procedures and aspirated. Hemostasis was noted after irrigation. Seprafilm was then placed between the rectosigmoid and vaginal cuff. Arista was also placed in this area to ensure hemostasis. 0 PDS loop PDS was used to close the fascial layer. 2-0 Vicryl interrupted was used to close the subcutaneous layer. 3-0 Monocryl subcutaneous was used to skin. Dermabond was placed on top of the skin. 12 mm port fascia was closed with 0 Vicryl. All ports were closed subcutaneously with interrupted 3-0 Monocryl and Dermabond
A 30 degree scope was then inserted into the bladder. Bladder was distended with saline. Both ureters jet flow were visualized. No suture was noted inside the bladder. No defects noted inside the bladder. The scope was then removed and Foley replaced. The patient was stable going to PACU. She is to stay overnight with a Foley in place receiving ampicillin, gentamicin and clindamycin for 24 hours. Sponge stick removed.
Disposition: PACU - hemodynamically stable.
Condition: stable
Attending present for entire procedure.
I was thinking I could use the 58660-78 for the first portion of the surgery and then the 58999-78 for Vaginal cuff repair but after reading the remaining of the op note and the procedure was converted to laparotomy, I was thinking I could capture the remaining surgery with the 49000-78 code, would you please advise, as I also do not believe any of the teleconference is able to be reimbursed. Thank you for your assistance, always much appreciated!
I am asking for guidance regarding CPT codes for this return to surgery after Laps Total Hyst done on 12/06/23. Please see op note below;
Procedure: Diagnostic laparoscopy, vaginal exam under anesthesia, dense lysis of adhesions, vaginal cuff repair, small bowel serosal oversew, cystoscopy and laparotomy
Procedures Date: 12/23/2023
Pre-op Diagnosis:
Hemoperitoneum
Vaginal bleeding
Post-operative Diagnosis:
Partial 0.5cm full-thickness vaginal cuff dehiscence 2 cm medial from the left angle
complete peritoneal dehiscence of the vaginal cuff
Dense adhesions from the rectosigmoid to the vaginal cuff
Dense adhesions from the small bowel to the right ovary
500ml hemoperitoneum
Anesthesia: General
Drains: none
Findings: Vaginal exam showed a 0.5 cm hole 2 cm medial from the left angle. Friable right angle of the vaginal cuff with partial necrosis. Bleeding noted from raw peritoneal edge. Multiple dense adhesions of the bowel to the pelvic sidewall bilaterally and to the vaginal cuff. 500 mL coagulated hemoperitoneum. Ileum serosal tear 30 cm from the ileocecal valve. Normal-appearing appendix. Unremarkable spleen and liver.
Consults: video telemedicine general surgery consult for small bowel serosal tear
Estimated Blood Loss: 600ml. 500 mL of hemoperitoneum evacuated with 100 mL intraoperatively bleeding
Total IV Fluids: 3000ml
Urine output: 485ml. Clear
Complications: small bowel serosal tear during lysis of adhesions oversewen with 4 interrupted sutures of 3-0 PDS. Patient tolerated the procedure well.
Indication and Consent:
Patient presented to the hospital with vaginal bleeding and hemoperitoneum status post total laparoscopic hysterectomy the robotic.
Procedure Details
The patient was taken to the Operating Room with IV fluid running and SCDs placed on bilateral lower extremeties. Patient was identified as XXX and the procedure verified. A Time Out was held and the above information confirmed. 2 grams of Ancef given with 500mg of flagyl. A Foley was placed.
After induction of general anesthesia, the patient was placed in modified dorsal lithotomy position in Allen type stirrups where she was prepped, draped, and catheterized in the normal, sterile fashion. Vaginal cuff was visualized with a weighted speculum and a right angle. A small 0.5 cm hole was noted 2 cm medial to the left angle. Several 2-0 Vicryl pop-off's were used for primary mucosal repair of the vaginal cuff. There is also raw edges of peritoneum noted to be bleeding. Rectal exam was performed with no defects noted. Staff was notified to prepare for laparoscopic entry. All vaginal instruments were removed and the sponge stick was replaced inside of the vaginal canal.
Two towel clamps were applied to elevate the base of umbilicus. A vertical skin incision was made across the umbilical folds after skin was infiltrated with 1% lidocaine with epinephrine. The Veress needle was introduced into the peritoneal cavity at a straight angle without difficulty at the umbilicus. A saline drop test was performed to validate intraperitoneal placement. The pneumoperitoneum was established with CO2 gas to the pressure of 15 mm Hg. A 5 mm trocar was inserted into the abdomen. Intraabdominal placement was confirmed with laparoscope. Patient was then placed in trendelenburg position. A 5mm trocar was then advanced under direct visualization of the laparoscope supraumbilically. The pneumoperitoneum was established with CO2 gas to the pressure of 15 mm Hg. A 5 mm trocar was inserted in the right lower quadrant under direct laparoscopic visualization after skin was infiltrated as above with lidocaine. A 12 mm trocar was inserted to the right lower quadrant under direct laparoscopic visualization. Laparoscopic suction was used to aspirate most of the hemoperitoneum. There was a Seshan of the right and left sidewall as well as the cuff was compromised due to dense adhesions of bowel. Blunt dissection to remove the right sidewall adhesion to the small bowel was performed. Once separated, the right ovary was mobile enough to move to visualize any active bleeding. No active bleeding was noted after aspirations of clots. Attention was was placed to the left sidewall where no signs of bleeding was noted. The vaginal cuff was densely adhesed to the sigmoid colon. After several attempts to separate, it was decided to convert to laparotomy. Pneumoperitoneum was released and trocars were removed.
A midline incision was made suprapubic to inferior umbilicus with a scalpel. Monopolar was used to dissect down to the fascial layer. Dissection of the rectus off the fascia was performed. The fascial incision was then extended to the skin incision to maximize visualization. The peritoneum was entered and extended being careful to avoid any damage to adhesions. Wet laparotomy sponges were placed in the abdominal cavity. O'Sullivan-O'Connor Retractor was used to help retract with a bladder blade. The right ovary was visualized thoroughly inspected. Again, no active bleeding was noted. Attention was then placed to the Sigmoid to vaginal cuff adhesion. Sharp dissection was performed to help separate the adhesion. Once the Sigmoid colon was released it was noted that there was a complete peritoneal dehiscence of the vaginal cuff. 200 mL of saline was then backfilled into the bladder to help identify the margins. The bladder was then decompressed. The cuff angle STRATAFIX sutures were then identified and grasped with hemostats. The peritoneal edge was then grasped with Allis clamps. The vaginal cuff closure needed with figure-of-eight using 0 Vicryl pop-off's. Monopolar energy was used on the right areas around the peritoneal edge. After the vaginal cuff was closed, we ran the bowel to assess for injury during extensive lysis of adhesions. During this, approximately 30 cm proximal from the ileocecal valve there was a sub-centimeter area noted with superficial serosal abrasion which occurred at time of adhesiolysis. Intra-operative consult for general surgery was made. The on-call surgery attending was performing another surgery at another hospital and was unavailable for in-person assistance. The surgery resident was consulted into the OR to observe the serosal tear. The surgery resident FaceTime Dr. B and showed the serosal injury. Dr. A spoke with Dr. B via teleconference. Dr. B recommended oversewing the bowel. This was performed with four seromuscular interrupted 3-0 PDS sutures parallel to the long axis of the bowel so as not to narrow the bowel lumen as recommended. The bowel was then ran again from the ileocecal valve to the ligament of Treitz. Copious irrigation was used in the abdominal cavity throughout the procedures and aspirated. Hemostasis was noted after irrigation. Seprafilm was then placed between the rectosigmoid and vaginal cuff. Arista was also placed in this area to ensure hemostasis. 0 PDS loop PDS was used to close the fascial layer. 2-0 Vicryl interrupted was used to close the subcutaneous layer. 3-0 Monocryl subcutaneous was used to skin. Dermabond was placed on top of the skin. 12 mm port fascia was closed with 0 Vicryl. All ports were closed subcutaneously with interrupted 3-0 Monocryl and Dermabond
A 30 degree scope was then inserted into the bladder. Bladder was distended with saline. Both ureters jet flow were visualized. No suture was noted inside the bladder. No defects noted inside the bladder. The scope was then removed and Foley replaced. The patient was stable going to PACU. She is to stay overnight with a Foley in place receiving ampicillin, gentamicin and clindamycin for 24 hours. Sponge stick removed.
Disposition: PACU - hemodynamically stable.
Condition: stable
Attending present for entire procedure.
I was thinking I could use the 58660-78 for the first portion of the surgery and then the 58999-78 for Vaginal cuff repair but after reading the remaining of the op note and the procedure was converted to laparotomy, I was thinking I could capture the remaining surgery with the 49000-78 code, would you please advise, as I also do not believe any of the teleconference is able to be reimbursed. Thank you for your assistance, always much appreciated!
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