GYN/Oncology surgery help

tgarne2

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I am coding a surgery for endometrial cancer , the procedures performed are exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy. I am not sure what codes/code to bill. I was thinking about 58210- Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s) but the para-aortic lymph node sampling was not done. I was also thinking about 58150 & 38770(separate procedure so unsure?) or 58150 w/22 modifier to account for the pelvic lymphadenectomy. Here is the operative report, any help would be appreciated.

PREOPERATIVE DIAGNOSIS:
Grade 1 endometrioid adenocarcinoma of the endometrium.

POSTOPERATIVE DIAGNOSIS:
Probable grade 1 to 2 endometrioid adenocarcinoma of the endometrium with minimal invasion.

PROCEDURES:
Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy.

ANESTHESIA:


ANESTHESIA TYPE:
General endotracheal.

SURGICAL FINDINGS:
Normal appearing ovaries and fallopian tubes bilateral, arcuate uterus. No enlarged lymph nodes.

PROCEDURE:
The risks, benefits, and options of the surgical procedure were discussed with the patient and her informed consent was confirmed. She was taken to the operating room, induced with general anesthesia and intubated without complication. She was positioned supine with her arms out to the side. She was prepped and draped in the usual sterile fashion with a Foley catheter in the urinary bladder. Antibiotics were administered intravenously. A timeout was performed with the entire operating room staff.

A skin incision was made from the umbilicus to the symphysis pubis. The abdomen was entered in the normal fashion. She was noted to have omentum adherent to the anterior abdominal wall. This was taken down with coagulation and transection taking care to avoid the bowel. The Bookwalter retractor was set up and the sidewalls were retracted laterally.

The entire abdomen and pelvis were inspected and no abnormalities were noted. Saline was infused in the pelvis. This was recollected and sent for cytology. The bowels were packed with moist laparotomy tapes and the Bookwalter retractor into the upper abdomen. The uterus was elevated. The round ligaments were coagulated and transected bilaterally. The retroperitoneal spaces were opened. The ureters were identified and noted to be coursing in the normal anatomic position. The ovarian vessels were isolated, coagulated and transected. The peritoneum below the ovaries and fallopian tubes were dissected up to the level of the uterus.

The peritoneum overlying the lower uterine segment was incised. There was noted to be scar tissue here from her previous cesarean section. Care was taken to dissect the bladder off of the lower uterine segment and cervix down to a level approximately 1.5 cm below the external cervical os. The uterine arteries were skeletonized bilaterally. They were then coagulated and transected. The cardinal ligaments were bilaterally and serially coagulated and transected down to the level of the external cervical os. With the bladder well out of harm's way, the vagina was opened using coagulation. This was then extended circumferentially, the uterus, cervix, bilateral ovaries, and fallopian tubes were sent for frozen section on the endometrium.

There was a great deal of bleeding from the vaginal cuff, 2-0 Vicryl figure-of-eight stitches were placed to maintain hemostasis. The remaining vaginal cuff was closed with a running 2-0 Vicryl suture. The pelvis was irrigated and aspirated. All areas of dissection were inspected and noted to be hemostatic. The frozen pathology returned as a probable grade 1 to 2 endometrioid adenocarcinoma with probable minimal invasion into the endometrium. A decision was made to perform a pelvic lymphadenectomy.

The retroperitoneal spaces were further opened. I began with the right-sided dissection. The Bookwalter retractor was used to retract the peritoneum facilitating exposure of the lymphatic beds. All adipose and lymphatic tissue was removed from the external iliac, internal iliac, and obturator spaces taking care to avoid the blood vessels and nerves. The boundaries of dissection were: Cephalad, the bifurcation of the common iliac arteries; Caudad, the deep circumflex iliac vein; deep, the obturator nerve; lateral, the pelvic sidewall; medial, the superior vesicle artery. Hemostasis was maintained throughout the dissection using coagulation. No enlarged lymph nodes were encountered. The identical steps were then undertaken on the left with the same boundaries of dissection. Care was taken to avoid the ureter, blood vessels and nerves. Excellent hemostasis was maintained using coagulation.

The entire pelvis was again irrigated and aspirated. All areas of dissection were inspected and noted to be hemostatic. The laparotomy tapes and instruments were removed from the upper abdomen. The omentum was brought down underneath the incision. With our sponge, needle, and instrument count correct, the fascia was closed with looped 0 PDS suture x2. The suprafascial tissue was irrigated. The skin was closed with 4-0 Vicryl. Dermabond was placed followed by a sterile dressing and an abdominal binder and the procedure was terminated.

Thanks in advance
Teresa Locke
CPC Iasishealthcare
 
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