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Wiki Help - Looking for some input

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Leandra

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Looking for some input on how to code the following op note: I have 58558 for the hysteroscope with D&C and 58670 for fulguration of oviduct(s) - I'm thinking I need to use the unlisted laparoscopic procedure for the removal of the Filshie clip - never coded this before. The clip is not stated as being "impacted" in the body of the notes so I didn't go with 58562 instead of 58558. Or, is the removal of the clip considered part of the fulguration? Any other ideas/suggestions/input would be great. Thanks in advance!

PREOPERATIVE DIAGNOSES:
1. Chronic pelvic pain.
2. Dysfunctional uterine bleeding.
3. History of carcinoma in situ.

POSTOPERATIVE DIAGNOSES:
1. Chronic pelvic pain.
2. Dysfunctional uterine bleeding.
3. History of carcinoma in situ.
4. Pelvic adhesions and a left Filshie clip was noted on the proximal end of the distal segment of tube.

OPERATIVE PROCEDURES:
1. Laparoscopic left tubal removal of Filshie clip or foreign body.
2. Fulguration of the left tube following removal of the Filshie clip.
3. Lysis of adhesions.
4. Hysteroscope with a dilatation and curettage.
 
Leandra said:
Looking for some input on how to code the following op note: I have 58558 for the hysteroscope with D&C and 58670 for fulguration of oviduct(s) - I'm thinking I need to use the unlisted laparoscopic procedure for the removal of the Filshie clip - never coded this before. The clip is not stated as being "impacted" in the body of the notes so I didn't go with 58562 instead of 58558. Or, is the removal of the clip considered part of the fulguration? Any other ideas/suggestions/input would be great. Thanks in advance!

PREOPERATIVE DIAGNOSES:
1. Chronic pelvic pain.
2. Dysfunctional uterine bleeding.
3. History of carcinoma in situ.

POSTOPERATIVE DIAGNOSES:
1. Chronic pelvic pain.
2. Dysfunctional uterine bleeding.
3. History of carcinoma in situ.
4. Pelvic adhesions and a left Filshie clip was noted on the proximal end of the distal segment of tube.

OPERATIVE PROCEDURES:
1. Laparoscopic left tubal removal of Filshie clip or foreign body.
2. Fulguration of the left tube following removal of the Filshie clip.
3. Lysis of adhesions.
4. Hysteroscope with a dilatation and curettage.
Click to expand...

The removal of the clip is just part of doing the fulguration of the tube...included.
 
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