smartin77
New
I am new to coding OB/GYN, I have the following OR Note, not sure if my coding should be 58558, 58350-59.
POST-OPERATIVE DIAGNOSIS:
Pelvic mass
Bilateral multicystic adnexal masses
Absence of fallopian tube patency
PROCEDURE:
Exam under anesthesia
Diagnostic laparoscopy
Collection of pelvic washings
Excision of peritoneal biopsies
Chromopertubation
Diagnostic hysteroscopy
Dilation and curettage
Attention was then turned to the patient's abdomen. Local anesthetic with 0.25% marcaine was applied to the inferior umbilicus. A small (5 mm) incision was made at the inferior umbilicus. Kocher clamps were used to elevate the fascia which was incised with a scalpel. The abdominal wall was tented while a Veress needle was inserted into the peritoneal cavity. Access to the intraperitoneal space was confirmed by a negative intraabdominal pressure and saline drop test. Pneumoperitoneum was obtained without difficulty and insufflated to a pressure of 15 mmHg. The Veress needle was then removed and a 5 mm trocar was inserted through the incision under direct visualization; access was confirmed with a laparoscope. The abdominal cavity and viscera were inspected for inadvertent injury during access and trocar placement. After identification of the median and medial umbilical ligaments along with the inferior epigastric vessels, right and left lower quadrant ports (5 mm) were placed under direct visualization lateral to these vessels after infiltration of local anesthetic with 0.25% marcaine. The abdomen and pelvis were surveyed which showed findings reported above.
Peritoneal washings were collected. Peritoneal biopsies were obtained from the anterior cul de sac and left abdominal wall using laparoscopic scissors. Both sites were noted to be hemostatic. Specimen were sent to pathology.
Dilute methylene blue was then injected through the manipulator to investigate patency of the fallopian tubes. Extravasation of dye was not visualized from either fallopian tube.
The Humi uterine manipulator was then removed from the vagina. A speculum was inserted into the patient's vagina. A tenaculum was applied to the anterior cervical lip. Using normal saline as the distending medium, the hysteroscope was inserted through the cervix and into the endometrial cavity without the need for cervical dilation, noting the findings above. The hysteroscope and attachments were then removed. Sharp curettage was applied to the endometrial cavity and several passes were performed in all quadrants of the endometrium until a gritty texture was obtained. The tenaculum was removed from the cervix and good hemostasis of the tenaculum sites was obtained with pressure.
POST-OPERATIVE DIAGNOSIS:
Pelvic mass
Bilateral multicystic adnexal masses
Absence of fallopian tube patency
PROCEDURE:
Exam under anesthesia
Diagnostic laparoscopy
Collection of pelvic washings
Excision of peritoneal biopsies
Chromopertubation
Diagnostic hysteroscopy
Dilation and curettage
Attention was then turned to the patient's abdomen. Local anesthetic with 0.25% marcaine was applied to the inferior umbilicus. A small (5 mm) incision was made at the inferior umbilicus. Kocher clamps were used to elevate the fascia which was incised with a scalpel. The abdominal wall was tented while a Veress needle was inserted into the peritoneal cavity. Access to the intraperitoneal space was confirmed by a negative intraabdominal pressure and saline drop test. Pneumoperitoneum was obtained without difficulty and insufflated to a pressure of 15 mmHg. The Veress needle was then removed and a 5 mm trocar was inserted through the incision under direct visualization; access was confirmed with a laparoscope. The abdominal cavity and viscera were inspected for inadvertent injury during access and trocar placement. After identification of the median and medial umbilical ligaments along with the inferior epigastric vessels, right and left lower quadrant ports (5 mm) were placed under direct visualization lateral to these vessels after infiltration of local anesthetic with 0.25% marcaine. The abdomen and pelvis were surveyed which showed findings reported above.
Peritoneal washings were collected. Peritoneal biopsies were obtained from the anterior cul de sac and left abdominal wall using laparoscopic scissors. Both sites were noted to be hemostatic. Specimen were sent to pathology.
Dilute methylene blue was then injected through the manipulator to investigate patency of the fallopian tubes. Extravasation of dye was not visualized from either fallopian tube.
The Humi uterine manipulator was then removed from the vagina. A speculum was inserted into the patient's vagina. A tenaculum was applied to the anterior cervical lip. Using normal saline as the distending medium, the hysteroscope was inserted through the cervix and into the endometrial cavity without the need for cervical dilation, noting the findings above. The hysteroscope and attachments were then removed. Sharp curettage was applied to the endometrial cavity and several passes were performed in all quadrants of the endometrium until a gritty texture was obtained. The tenaculum was removed from the cervix and good hemostasis of the tenaculum sites was obtained with pressure.