My question is on this case shown below regarding the diagnosis extent of severe adhesive on the 58661 would it be correct to use the K66.0 instead of the N73.6 for that code only due to liver perforation?
58661 with modifier 22, 50 with N93.8, N73.6 K91.72
58558 N83.8, N73.6
Findings: hysteroscopy, normal uterine cavity, normal tubal ostia; laparoscopy: severe pelvic adhesive disease, normal appearing ovaries, paratubal cysts on fallopian tubes, see OP note for details
A Foley catheter was used to drain the bladder. A bimanual exam was performed and the uterus was noted to be retroverted. A weighted speculum was placed into the posterior aspect of the vagina, and the anterior lip of the cervix was grasped with a single-toothed tenaculum and drawn forward. The uterus sounded to 9 cm. The cervix was then gently serially dilated using Pratt dilators to accommodate the Symphion hysteroscope. The hysteroscope was then advanced into the uterine cavity, and the cavity and endometrial lining were surveyed with the above noted findings. The hysteroscope was then removed. The small sharp curet was then advanced into the uterine cavity and the endometrium was curetted to a uniform gritty consistency. The specimens of endometrium were sent to Pathology for examination. A diagnostic V-care was placed into the uterus for uterine manipulation.
Attention was then turned to the patient's abdomen. The Palmer's point was identified and was anesthetized with 2 mL of 0.25 percent Marcaine. A 5 mm skin incision was made with the scalpel. A Veress needle was used to attempt to enter the abdomen, but unable to verify correct placement using saline drop test, so the Veress needle was removed and direct visualization was used for placement. The scope with 5mm trocar was advanced and intraabdominal placement was confirmed. Once Intra-abdominal insufflation was noted to be adequate, a survey of the abdominal contents noted severe adhesive disease with adhesions attached to anterior abdominal wall were noted along the outlines of large abdominal hernia mesh.
Normal-appearing uterus with normal-appearing ovaries and bilateral fallopian tubes with paratubal cysts were present. The patient was placed in Trendelenburg. At this time, the RLQ region was transilluminated and an accessory trocar site was mapped out. The skin was first anesthetized with 2 mL of 0.25 percent Marcaine. Under direct visualization with the laparoscope, an 5 mm skin incision was made with the scalpel and the 5 mm trocar was placed under direct visualization with the laparoscope successfully. Same procedure was performed for a LLQ port entry and an 5mm trocar was placed. Significant adhesions were noted along the entirety of the anterior abdominal wall following the placements of the LLQ and RLQ trocars. The camera was then placed in the LLQ port and a survey of the upper abdomen was performed, noted dense bowel and liver adhesions. It was noted that the initial trocar site was protruding from the lateral edge of the left lobe of the liver. No bleeding around that site. At this time, call to colorectal surgery who was in-house as well as trauma was made. The on-call general surgeon was called. Dr W arrived. See his consult note for details. Dr P also arrived while Dr W was performing his evaluation and was present until the liver was evaluated, treated and noted to be stable.
Please see Dr W intra-op consult for lysis of adhesions and management of liver perforation.
Once Dr W completed his portion of the procedure and the liver was noted to be stable, we were given clearance to continue with the remainder of the surgery. Recommendations by trauma surgery to follow H&H q 6 hours overnight was made.
We were able to visualize both fallopian tubes in their entirety down to the fimbriated ends. The laparoscopic grasper was used to elevate the left fallopian tube by the fimbria, and the Ligature was used to grasp, cauterize and transect the mesoteres from proximal to distal. The tube was then removed in its entirety. The same procedure was performed on the right fallopian tube. This was performed successfully. The ovaries were again evaluated and noted to be normal in appearance and the decision not to remove them was made. Pictures were taken. Everything including the liver site and bowel/omentum appeared hemostatic and stable, therefore, all instruments were removed from the abdomen. The camera was removed and the gas was stopped and then evacuated from the trocar port sites. Once all gas appeared removed, the trocars were removed successfully. The abdomen was cleaned with warm sterile saline. The incision sites were dried, closed with 4-0 Monocryl subcutaneously, then Dermabond was applied over the skin incision sites.
The diagnostic Vcare was removed from the vagina and foley catheter removed from the bladder. All sponge, lap, and needle counts were correct throughout the procedure. The patient tolerated the procedure well and was taken to the recovery room. Pt will be placed on antibiotics postop.
58661 with modifier 22, 50 with N93.8, N73.6 K91.72
58558 N83.8, N73.6
Findings: hysteroscopy, normal uterine cavity, normal tubal ostia; laparoscopy: severe pelvic adhesive disease, normal appearing ovaries, paratubal cysts on fallopian tubes, see OP note for details
A Foley catheter was used to drain the bladder. A bimanual exam was performed and the uterus was noted to be retroverted. A weighted speculum was placed into the posterior aspect of the vagina, and the anterior lip of the cervix was grasped with a single-toothed tenaculum and drawn forward. The uterus sounded to 9 cm. The cervix was then gently serially dilated using Pratt dilators to accommodate the Symphion hysteroscope. The hysteroscope was then advanced into the uterine cavity, and the cavity and endometrial lining were surveyed with the above noted findings. The hysteroscope was then removed. The small sharp curet was then advanced into the uterine cavity and the endometrium was curetted to a uniform gritty consistency. The specimens of endometrium were sent to Pathology for examination. A diagnostic V-care was placed into the uterus for uterine manipulation.
Attention was then turned to the patient's abdomen. The Palmer's point was identified and was anesthetized with 2 mL of 0.25 percent Marcaine. A 5 mm skin incision was made with the scalpel. A Veress needle was used to attempt to enter the abdomen, but unable to verify correct placement using saline drop test, so the Veress needle was removed and direct visualization was used for placement. The scope with 5mm trocar was advanced and intraabdominal placement was confirmed. Once Intra-abdominal insufflation was noted to be adequate, a survey of the abdominal contents noted severe adhesive disease with adhesions attached to anterior abdominal wall were noted along the outlines of large abdominal hernia mesh.
Normal-appearing uterus with normal-appearing ovaries and bilateral fallopian tubes with paratubal cysts were present. The patient was placed in Trendelenburg. At this time, the RLQ region was transilluminated and an accessory trocar site was mapped out. The skin was first anesthetized with 2 mL of 0.25 percent Marcaine. Under direct visualization with the laparoscope, an 5 mm skin incision was made with the scalpel and the 5 mm trocar was placed under direct visualization with the laparoscope successfully. Same procedure was performed for a LLQ port entry and an 5mm trocar was placed. Significant adhesions were noted along the entirety of the anterior abdominal wall following the placements of the LLQ and RLQ trocars. The camera was then placed in the LLQ port and a survey of the upper abdomen was performed, noted dense bowel and liver adhesions. It was noted that the initial trocar site was protruding from the lateral edge of the left lobe of the liver. No bleeding around that site. At this time, call to colorectal surgery who was in-house as well as trauma was made. The on-call general surgeon was called. Dr W arrived. See his consult note for details. Dr P also arrived while Dr W was performing his evaluation and was present until the liver was evaluated, treated and noted to be stable.
Please see Dr W intra-op consult for lysis of adhesions and management of liver perforation.
Once Dr W completed his portion of the procedure and the liver was noted to be stable, we were given clearance to continue with the remainder of the surgery. Recommendations by trauma surgery to follow H&H q 6 hours overnight was made.
We were able to visualize both fallopian tubes in their entirety down to the fimbriated ends. The laparoscopic grasper was used to elevate the left fallopian tube by the fimbria, and the Ligature was used to grasp, cauterize and transect the mesoteres from proximal to distal. The tube was then removed in its entirety. The same procedure was performed on the right fallopian tube. This was performed successfully. The ovaries were again evaluated and noted to be normal in appearance and the decision not to remove them was made. Pictures were taken. Everything including the liver site and bowel/omentum appeared hemostatic and stable, therefore, all instruments were removed from the abdomen. The camera was removed and the gas was stopped and then evacuated from the trocar port sites. Once all gas appeared removed, the trocars were removed successfully. The abdomen was cleaned with warm sterile saline. The incision sites were dried, closed with 4-0 Monocryl subcutaneously, then Dermabond was applied over the skin incision sites.
The diagnostic Vcare was removed from the vagina and foley catheter removed from the bladder. All sponge, lap, and needle counts were correct throughout the procedure. The patient tolerated the procedure well and was taken to the recovery room. Pt will be placed on antibiotics postop.
