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Hiii!! How would you code this procedure??? I'm thinking in 58580, and was actually the code we used to get auth. But hospital coded as 58356. Any advice please???
Procedure: Transcervical uterine fibroid ablation w/ us guidance, hysteroscopy, D & C.
Notes: The pt was taken to the operating room. She underwent general anesthesia. She was prepped and draped in usual sterile fashion. The weighted speculum and deaver were used to visualize the cervix. The anterior lip of the cervix grasped w/ a single tooth tenaculum. The uterus was sounded to a depth of 8 cm. The endocervical cavity as distended w fluids and the cavity was visualized w above findings. The hysteroscope was removed. a sharp curettage was performed. Tissue obtained was sent top pathology for analysis.
The cervix was dilated to 22 French. The treatment device w integrated ultrasound and radiofrequency energy delivery system was inserted into the uterine cavity. Global assessment was performed identifying the myoma. A right side, type 4, measuring 3.56 x 4.6 cm was treated. A graphical overlay was placed to target the ablation zone. A trocar tip was introduced. Care was taken to ensure that the guide was within the serosal boundary and needle electrodes were deployed. A safety check was again performed. Radial frequency ablation was performed for 3:48 min. 2 additional ablations were performed for approximately 2:48 min and 2:06 min each, following the above techniques. No other myomas were identified. The endometrium was spared. All instruments were removed from the vagina. Hemostasis was assured.
Procedure: Transcervical uterine fibroid ablation w/ us guidance, hysteroscopy, D & C.
Notes: The pt was taken to the operating room. She underwent general anesthesia. She was prepped and draped in usual sterile fashion. The weighted speculum and deaver were used to visualize the cervix. The anterior lip of the cervix grasped w/ a single tooth tenaculum. The uterus was sounded to a depth of 8 cm. The endocervical cavity as distended w fluids and the cavity was visualized w above findings. The hysteroscope was removed. a sharp curettage was performed. Tissue obtained was sent top pathology for analysis.
The cervix was dilated to 22 French. The treatment device w integrated ultrasound and radiofrequency energy delivery system was inserted into the uterine cavity. Global assessment was performed identifying the myoma. A right side, type 4, measuring 3.56 x 4.6 cm was treated. A graphical overlay was placed to target the ablation zone. A trocar tip was introduced. Care was taken to ensure that the guide was within the serosal boundary and needle electrodes were deployed. A safety check was again performed. Radial frequency ablation was performed for 3:48 min. 2 additional ablations were performed for approximately 2:48 min and 2:06 min each, following the above techniques. No other myomas were identified. The endometrium was spared. All instruments were removed from the vagina. Hemostasis was assured.