AR2728
Expert
Patient presents for exam under anesthesia with intended LEEP or Cold Knife Conization. Patient was placed under general anesthesia. The cervix could be semi-palpitated through the vaginal mucosa, however, no actual cervical opening or gross cervical tissue could be identified. Both Allis and single toothed tenaculum clamps were used to grasp the mucosa and the projected cervix in conjunction with bimanual exam to help identify where the cervix was. The actual cervix or opening could never be identified with the appearance of vaginal mucosa overgrowing the cervix unclear where the dysplasia is coming from Lugol solution was used to paint the entire pericervical and vaginal area with no gross lesions identified for resection. Due to the severe amount of atrophy and unable to actually identify the mid point of the cervix away from the bladder or rectum, it was unsafe to continue with a cold knife cone or LEEP procedure and the patient would be better served to have a hysterectomy performed and removal of the uterus and cervix as unable to find the location of her dysplasia and the cervix is completely overgrown with vaginal mucosa.
I fully believe this is a discontinued procedure as the intent was the Leep or cold knife conization, anesthesia was administered, but it was unsafe for the patient to proceed. However, since each procedure has it's own CPT code 57520 or 57522-which do I use with -53 modifier? Any thoughts on this?
I fully believe this is a discontinued procedure as the intent was the Leep or cold knife conization, anesthesia was administered, but it was unsafe for the patient to proceed. However, since each procedure has it's own CPT code 57520 or 57522-which do I use with -53 modifier? Any thoughts on this?