tloeb
Networker
Indications: 63 y.o. female G2P0011 with unusual brown particulate discharge that was not able to be fully evaluated in the office. Full PARQ session was held prior to the procedure and formal surgical consents were signed.
Findings: Vaginally, there was white/clear discharge noted. No areas of brown. No areas of skin abrasion or fistula. Normal tissue. Cervix present with canal about 3cm in length due to prior supracervical hysterectomy. In the cervical canal there was no large polyps or granulation tissue. Very slight protuberance at the anterior wall that could represent a polypoid lesion.
Procedure:
The patient was met in the preoperative area where procedure was confirmed. She was then taken to the operating room when she was placed in dorsal supine position. SCDs were placed and confirmed pumping. Antibiotic prophylaxis was addressed--none were indicated. Team pause was held. General MAC anesthesia was induced without difficulty. She was then repositioned into dorsal lithotomy with Allen stirrups in what was felt to be a neurologically safe position. Exam under anesthesia was performed. Findings are noted above. There was no source of discharge noted. All skin was intact and normal in appearance. She was then prepped vaginally and draped in the normal sterile fashion.
An open-sided speculum was placed in the vagina to visualize the cervix. The cervix was grasped with a single tooth tenaculum. The external os of the cervix was carefully dilated to 5 mm. Remainder of the hysteroscopy/cervicoscopy was done with hydropressure.
The 6mm Smith and Nephew Truclear hysteroscope was inserted into the cervical canal was notable for visualization of findings above. Careful inspection was performed. The polypoid lesion on the anterior wall was excised with the Truclear soft tissue mini blade. Additional sampling was performed around the cervical canal. All specimens were sent to pathology.
I am planning to use the unlisted Hysteroscopy code 58579 because of the absence of the uterus but am struggling with what to compare this to. Maybe a colpo code - 57454? Should the wRVU be increased because of the hysteroscope?
Findings: Vaginally, there was white/clear discharge noted. No areas of brown. No areas of skin abrasion or fistula. Normal tissue. Cervix present with canal about 3cm in length due to prior supracervical hysterectomy. In the cervical canal there was no large polyps or granulation tissue. Very slight protuberance at the anterior wall that could represent a polypoid lesion.
Procedure:
The patient was met in the preoperative area where procedure was confirmed. She was then taken to the operating room when she was placed in dorsal supine position. SCDs were placed and confirmed pumping. Antibiotic prophylaxis was addressed--none were indicated. Team pause was held. General MAC anesthesia was induced without difficulty. She was then repositioned into dorsal lithotomy with Allen stirrups in what was felt to be a neurologically safe position. Exam under anesthesia was performed. Findings are noted above. There was no source of discharge noted. All skin was intact and normal in appearance. She was then prepped vaginally and draped in the normal sterile fashion.
An open-sided speculum was placed in the vagina to visualize the cervix. The cervix was grasped with a single tooth tenaculum. The external os of the cervix was carefully dilated to 5 mm. Remainder of the hysteroscopy/cervicoscopy was done with hydropressure.
The 6mm Smith and Nephew Truclear hysteroscope was inserted into the cervical canal was notable for visualization of findings above. Careful inspection was performed. The polypoid lesion on the anterior wall was excised with the Truclear soft tissue mini blade. Additional sampling was performed around the cervical canal. All specimens were sent to pathology.
I am planning to use the unlisted Hysteroscopy code 58579 because of the absence of the uterus but am struggling with what to compare this to. Maybe a colpo code - 57454? Should the wRVU be increased because of the hysteroscope?
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