I need help coding the following: I believe I come up with dx's 614.6 and 568.0, 625.9 with cpt 58660 or should I go unlisted 49329. I need some input. See attached report:
PREOPERATIVE DIAGNOSIS: Chronic abdominal and pelvic pain.
POSTOPERATIVE DIAGNOSIS: Extensive abdominopelvic adhesions.
OPERATION:
1. Laparoscopy.
2. Extensive adhesiolysis.
SURGEON:
ANESTHESIA: General
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: Minimal.
SPECIMEN:
FLUIDS:
FINDINGS:
DESCRIPTION OF PROCEDURE: After induction of adequate general anesthesia, the patient was prepped and draped in the usual sterile manner in the dorsi lithotomy position. Urinary bladder was drained continuously with a Foley catheter. Exam under anesthesia revealed a small, anterior and mobile uterus and normal adnexa. A speculum was placed in the vagina. The anterior lip of the cervix was grasped with a single-tooth tenaculum. The uterus was sounded to 7 centimeters. The os was dilated slightly. The HUMI cannula was inserted. The bulb inflated and the single-tooth tenaculum and speculum were removed. Attention was turned to the abdomen. A 2-centimeter midline umbilical incision was made and carried down to the peritoneum in the usual fashion. The peritoneum was entered bluntly. The incision was extended with blunt retraction. The laparoscopic sheath and trocar were inserted. The trocar was removed and the laparoscope was inserted into the abdomen. The abdomen was continuously insufflated throughout the procedure maintaining a pressure of less than 15. There was a broad band of omental adhesions in the midline extending from just below the umbilicus down to the pubic area. A 1-centimeter incision was made in the left lower quadrant and a 5-millimeter sheath and trocar were inserted. The trocar was removed. The Harmonic scalpel was then used to coagulate and transect the omental adhesions to the anterior abdominal wall. Once that was accomplished the Prestige was inserted and the abdomen and pelvis were explored. The liver and gallbladder appeared normal. Appendix appeared normal. Visualized in the pelvis, the uterus itself appeared normal. The bladder was adherent relatively high on the anterior abdominal wall presumably from the patient's previous cesarean section. Left tube and ovary appeared normal. There was evidence of bilateral tubal ligation. There was an omental adhesion to the right ovary. The ovaries were freely mobile. The cul-de-sac appeared normal, no evidence of endometriosis. A 1-centimeter incision was made in the right lower quadrant and a second 5-millimeter sheath and trocar were inserted. Trocar was removed and operating instruments were inserted. The adhesions involving the right ovary were taken down with a Harmonic scalpel. The adhesions involving the bladder anteriorly were then taken down with the Harmonic scalpel. Once that was accomplished the pressured was taken down in the abdomen to 5. Hemostasis was noted to be good. The operating instruments and lower sheaths were removed under direct visualization. Once adequate hemostasis was assured, the abdomen was deflated. The laparoscope and sheath were removed from the umbilicus. The umbilical incision was closed with a deeper layer of figure-of-eight 0 Vicryl through the fascia. The subcutaneous tissue was closed with a figure-of-eight 0 Vicryl and the skin edges approximated with subcuticular 4-0 Vicryl. The right and left lower quadrant incisions were closed with suprapubic 4-0 Vicryl. Sterile dressings were applied. The HUMI cannula was removed. The procedure was terminated and patient was taken to the recovery room in good condition.
PREOPERATIVE DIAGNOSIS: Chronic abdominal and pelvic pain.
POSTOPERATIVE DIAGNOSIS: Extensive abdominopelvic adhesions.
OPERATION:
1. Laparoscopy.
2. Extensive adhesiolysis.
SURGEON:
ANESTHESIA: General
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: Minimal.
SPECIMEN:
FLUIDS:
FINDINGS:
DESCRIPTION OF PROCEDURE: After induction of adequate general anesthesia, the patient was prepped and draped in the usual sterile manner in the dorsi lithotomy position. Urinary bladder was drained continuously with a Foley catheter. Exam under anesthesia revealed a small, anterior and mobile uterus and normal adnexa. A speculum was placed in the vagina. The anterior lip of the cervix was grasped with a single-tooth tenaculum. The uterus was sounded to 7 centimeters. The os was dilated slightly. The HUMI cannula was inserted. The bulb inflated and the single-tooth tenaculum and speculum were removed. Attention was turned to the abdomen. A 2-centimeter midline umbilical incision was made and carried down to the peritoneum in the usual fashion. The peritoneum was entered bluntly. The incision was extended with blunt retraction. The laparoscopic sheath and trocar were inserted. The trocar was removed and the laparoscope was inserted into the abdomen. The abdomen was continuously insufflated throughout the procedure maintaining a pressure of less than 15. There was a broad band of omental adhesions in the midline extending from just below the umbilicus down to the pubic area. A 1-centimeter incision was made in the left lower quadrant and a 5-millimeter sheath and trocar were inserted. The trocar was removed. The Harmonic scalpel was then used to coagulate and transect the omental adhesions to the anterior abdominal wall. Once that was accomplished the Prestige was inserted and the abdomen and pelvis were explored. The liver and gallbladder appeared normal. Appendix appeared normal. Visualized in the pelvis, the uterus itself appeared normal. The bladder was adherent relatively high on the anterior abdominal wall presumably from the patient's previous cesarean section. Left tube and ovary appeared normal. There was evidence of bilateral tubal ligation. There was an omental adhesion to the right ovary. The ovaries were freely mobile. The cul-de-sac appeared normal, no evidence of endometriosis. A 1-centimeter incision was made in the right lower quadrant and a second 5-millimeter sheath and trocar were inserted. Trocar was removed and operating instruments were inserted. The adhesions involving the right ovary were taken down with a Harmonic scalpel. The adhesions involving the bladder anteriorly were then taken down with the Harmonic scalpel. Once that was accomplished the pressured was taken down in the abdomen to 5. Hemostasis was noted to be good. The operating instruments and lower sheaths were removed under direct visualization. Once adequate hemostasis was assured, the abdomen was deflated. The laparoscope and sheath were removed from the umbilicus. The umbilical incision was closed with a deeper layer of figure-of-eight 0 Vicryl through the fascia. The subcutaneous tissue was closed with a figure-of-eight 0 Vicryl and the skin edges approximated with subcuticular 4-0 Vicryl. The right and left lower quadrant incisions were closed with suprapubic 4-0 Vicryl. Sterile dressings were applied. The HUMI cannula was removed. The procedure was terminated and patient was taken to the recovery room in good condition.