cubbiecatz
Networker
I am in need of help for a cpt code for Excision of leiomyoma of right vulva. I am wondering if 56630 will fit this scenario.
I have my codes for the other procedures, but this is my first time seeing a vulvar leiomyoma.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room where she was identified as xxx. She was laid in the supine position given general LMA anesthesia. Legs were placed in the Allen stirrups she was prepped and draped in usual sterile manner. A timeout was performed indicating the above-named procedure.
The right vulva was inspected and what was felt to be a Bartholin cyst initially, turned out to be a leiomyoma of the right labia majora. An incision on the right labia was made from the anterior portion of the right labia posterior to and lateral to the anus. The underlying fibroid was excised. Dr. Brestel had been called to the operating room for second pair of hands. The underlying area was bleeding and this was controlled by sewing with 2-0 Vicryl the bulbocavernosus muscle and capsule back together in interrupted sutures. The transversus peroneus was also sewed back together with 2-0 Vicryl in interrupted sutures. The subcutaneous tissues were then sewn back together from anterior to posterior with 2-0 Vicryl in interrupted sutures.. The external anal sphincter was then sewed back together posteriorly and interrupted sutures of 2-0 Vicryl. The subcutaneous tissues were then reapproximated using 3-0 Vicryl. The skin was closed with interrupted sutures of 3-0 Vicryl. There was noted to be good hemostasis.
Attention turned to the condyloma and skin tags. On a power setting of 8 W continuous, CO2 laser was utilized to vaporize the skin tags followed by the posterior perineal flap condyloma, the perineal raise condyloma in the anal condyloma. Perfect hemostasis was noted. This completed the procedure. The patient was then cleaned off, extubated and transported to recovery in stable condition.
Thank you, Cathy
I have my codes for the other procedures, but this is my first time seeing a vulvar leiomyoma.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room where she was identified as xxx. She was laid in the supine position given general LMA anesthesia. Legs were placed in the Allen stirrups she was prepped and draped in usual sterile manner. A timeout was performed indicating the above-named procedure.
The right vulva was inspected and what was felt to be a Bartholin cyst initially, turned out to be a leiomyoma of the right labia majora. An incision on the right labia was made from the anterior portion of the right labia posterior to and lateral to the anus. The underlying fibroid was excised. Dr. Brestel had been called to the operating room for second pair of hands. The underlying area was bleeding and this was controlled by sewing with 2-0 Vicryl the bulbocavernosus muscle and capsule back together in interrupted sutures. The transversus peroneus was also sewed back together with 2-0 Vicryl in interrupted sutures. The subcutaneous tissues were then sewn back together from anterior to posterior with 2-0 Vicryl in interrupted sutures.. The external anal sphincter was then sewed back together posteriorly and interrupted sutures of 2-0 Vicryl. The subcutaneous tissues were then reapproximated using 3-0 Vicryl. The skin was closed with interrupted sutures of 3-0 Vicryl. There was noted to be good hemostasis.
Attention turned to the condyloma and skin tags. On a power setting of 8 W continuous, CO2 laser was utilized to vaporize the skin tags followed by the posterior perineal flap condyloma, the perineal raise condyloma in the anal condyloma. Perfect hemostasis was noted. This completed the procedure. The patient was then cleaned off, extubated and transported to recovery in stable condition.
Thank you, Cathy
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