Wiki diagnostic laparoscopy

ebruton

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I need some help on this case.

The Dr. is saying this is a diagnostic laparoscopy due to pelvic pain

"To begin the procedure, I placed a speculum into the vagina. The anterior lip of the cervix was grasped with a single-tooth tenaculum. Cervix was sequentially dilated. Attempt at the HUMI placement was unsuccessful. The tenaculum came off, the cervix was
bleeding, and at this point, ring forceps was placed to tamponade this area on the cervix, and no HUMI was placed."

a 5 mm vertical incision was made and a 5 mm trocar was placed. Once entry was confirmed into the abdomen, approximately 3 L of carbon dioxide was used to insufflate the abdomen.

The patient was placed in Trendelenburg position and another 5 mm port was placed in the left lower quadrant after injection with local anesthetic and incision was made and then the trocar was placed under direct visualization without injury to the underlying
viscera or vasculature. The findings were as noted above. Again, no evidence of any active endometriosis, ovarian cyst, or intrapelvic pathology was noted. Gas was removed. Trocars removed. Skin sites were closed with 4-0 Monocryl. Steri-Strips were
placed. The ring forceps was removed. A speculum was placed in the vagina. There was still bleeding noted at the anterior lip of cervix due to the prior tenaculum site. A 0 Vicryl suture was placed, which controlled the bleeding and then the speculum and all
instruments removed from below


I was initially thinking 49320 but the report doesnt say brushing or washing was done and then there was bleeding in which sutures were placed.

Thank you
 
49320 is laparoscopy, abdomen, peritoneum & omentum, diagnostic, with or without collection of specimen by brushing or washing.
Since it is with or without, it doesn't matter if the physician did not do a collection. 49320 seems correct.
Regarding the bleeding and sutures, it appears the physician created the minor injury at the beginning of the procedure when trying to place the HUMI. When the bleeding had not stopped by the end of the procedure, physician put in a suture. You can't bill for repairing your own injury.
 
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