Gyn oncology

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I am recently new to GYN Oncology although I have been doing OB/GYN since 2004. I am needing some help with billing for a procedure that includes a left inguinal lymph node debulking. I'm not exactly sure what code I need to use for these procedures from the 58943 through the 58956 codes and if I need the extra code for the lymph node debulking or if this is going to be included in the main procedure. I would greatly appreciate any help with this.

These are the procedures that the physician performed; 1. Exam under anesthesia. 2. Exploratory laparotomy. 3. Modified radical hysterectomy with bilateral salpingo-oophorectomy. 4. Bilateral pelvic and periaortic lymph node dissection. 5. Omentectomy. 6. Left inguinal lymph node debulking.

Operative Report

Vertical midline incision was made through the skin, subcutaneous tissue, and anterior rectus sheath.* Peritoneum was entered sharply.* Exploration was performed.* The Bookwalter retractor was placed.

Retraction was provided and the transverse colon mobilized until the entire greater omentum along the infracolic portion could be identified.* This omentum was then removed starting at the hepatic flexure and continuing to the splenic flexure.**

Removal of process involved generating pedicles that were subsequently transected with the Impact device.

The lesser sac was then developed.* The lesser omentum along the greater curvature of the stomach was then also removed.* The Impact device was utilized for this as well.

A Bookwalter retractors were repositioned to give exposure to the pelvis.* The left round ligament was transected.* The peritoneum was incised lateral and parallel at the left infundibulopelvic vessels.* The left ureter was identified.* The left infundibulopelvic vessels were transected with the Impact device.* The left adnexa was mobilized on the medial leaf of the broad ligament.* It was then crossclamped at the utero-ovarian pedicle with a Pean clamp.* The left adnexa was submitted for frozen.* A similar procedure was repeated in the opposite side except that it was not submitted for frozen.

The uterovesical peritoneal reflection was incised.* The bladder was mobilized off the lower uterine segment and anterior cervicovaginal junction.* Partial transection of the cardinal ligament was performed with the Impact device.* With cephalad pressure on the sponge stick, an anterior colpotomy was performed.* The vaginal dissection then continued circumferentially utilizing the Impact device.* The rectovaginal septum was developed.* The dissection continued posteriorly to incorporate the posterior paravaginal, and perirectal tissues.* The pelvic plaque was able to be dissected off the rectosigmoid colon without a colotomy.* To double-checked this, the pelvis was filled with water and a rigid Procto tube was inserted into the rectum.* The colon was distended under pressure and there were no bubbles.

There were some minor muscularis injuries inherent to resection/debulking of that cul-de-sac mass.* These areas were oversewn in an imbricating fashion with interrupted suture of 3-0 Polysorb.
Next, a Sonicision device was used to remove the adipose and lymph node tissue overlying the left external iliac artery from the level of the bifurcation of hypogastric vessels in a caudal direction left deep circumflex iliac vein.* Added to the left pelvic specimen was the adipose and lymph node tissue lying posterior to left external iliac vein, but anterior to left obturator nerve.* Next, the adipose and lymph node tissue lying lateral to left common iliac artery was removed from the level of bifurcation of hypogastric vessels in a cephalad direction of bifurcation of the aorta.* Next, the adipose and lymph node tissue lying lateral to the aorta was removed from the level of bifurcation of the aorta in a cephalad direction until it was just caudal of the left renal vein.* Similar dissection was repeated in the opposite side.

The pelvic and abdominal cavity was irrigated.* With no other evidence of obvious disease, an unknown inguinal metastasis in the left side, decision was made to close the fascia.* The fascia was reapproximated with 2 sutures of #1 looped Surgipro placed in a running fashion, and tied each other in the middle.* Subcutaneous tissue was irrigated, and the skin was reapproximated with staples.* Sterile dressing was applied.

A 7 cm curvilinear incision was made over the left inguinal area.* The subcutaneous tissue was transected with monopolar cautery.* The palpably enlarged lymph node could be easily appreciated.* Circumferential dissection was performed in the femoral triangle.* The inguinal ligament was identified.* The femoral vessels were identified.* Adenopathy was debulked with the dissection utilizing either the Impact device, or monopolar cautery.* A 10 flat drain was then placed in the base of this wound and brought out through a small incision approximately 8 cm cephalad of the lateral apex.* The drain was secured to the skin with 2-0 nylon suture.* The wound was closed with staples.* Sterile dressing was applied.* The patient was extubated and transported to the recovery room in stable condition.

Thank you for your help.
 
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