maine4me
Guru
I need some clarification. I am coding the following operative report. And have determined that these are the appropriate CPT codes: 58301, 58661-LT, 58670-RT 51. Am I on the right track... the 58661 is confusing me since it is listed as a bilateral procedure, however I do not see a comperable unilateral procedure.
PREOPERATIVE DIAGNOSIS:
1. Retained IUD.
2. Chronic left-sided pelvic pain.
3. Request for permanent sterilization.
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE:
1. IUD retrieval.
2. Diagnostic laparoscopy.
3. Left salpingo-oophorectomy.
4. Lysis of adhesions.
5. Tubal cautery of right fallopian tube.
SURGEON: Dr. Elizabeth Hamilton.
ASSISTANT: Dr. Donald DeBrakaleer
FINDINGS: The uterus was noted to be of normal size, shape, and consistency. No adnexal
masses were grossly appreciated. There was no prolapse noted. The left ovary and tube
appeared within normal limits with some mild round ligament and omental adhesions. The
right fallopian tube and ovary were totally within normal limits. Liver and gallbladder
edge were within normal limits.
COMPLICATIONS: None.
CONDITION: Stable to recovery.
BRIEF SUMMARY: The patient was identified by both the surgeon and anesthesiologist and
brought back to Operating Room #4 where general endotracheal anesthesia was administered.
She was then appropriately placed in the bean bag and placed in the dorsal lithotomy
position. She was prepped and draped in usual sterile fashion. A Foley catheter was
aseptically placed. A bimanual exam was then performed which revealed no adnexal masses
and a normal anteverted size, shape, and consistency to her uterus. At this time, a
breakaway speculum was placed in the vaginal cavity, the cervix easily visualized and
grasped with an Allis clamp. A Pratt dilator was placed in the cervical canal and taped
with sterile Steri-Strips. At this time, gloves were changed and attention was then
turned back to the patient's abdomen. Approximately 5 cc of half percent Marcaine was
injected in a subumbilical portion of skin. This area was elevated with an Allis clamp
and a vertical skin incision was created approximately 5 mm. Veress needle was placed
and the syringe test was performed and noted to be correct. The abdomen was allowed to
fill with approximately 2 liters of CO2 gas when the pressure began to rise. Using a 5 mm
trocar, it was directly inserted under direct visualization. The abdomen and pelvis were
then examined. No underlying injuries were noted. The right and left fallopian tube and
ovary appeared within normal limits. There was noted to be some minimal left round
ligament adhesions. The left omentum was also adhesed to the sidewall. The right ovary
and tube appeared within normal limits. The liver and gallbladder edge appeared within
normal limits. At this time, a second trocar site was chosen in her right lower quadrant.
This was chosen in the area of her C-section scar. It was transilluminated and then
injected with approximately 2.5 cc of half percent Marcaine. A 5 mm skin incision was
created and a 5 mm trocar was directly inserted under direct visualization. The same
procedure was repeated in the left lower quadrant and under direct visualization a 10 mm
trocar was inserted. The right fallopian tube was cauterized using a Kleppinger forceps
until the ammeter read 0 down to the mesosalpinx. Approximately 2 cm portion of tube was
cauterized in its isthmic portion. The left ovary and tube were then examined. The
adhesions in the right round ligament, as well as the omentum were taken down bluntly and
sharply. Hemostasis was noted to be excellent. Attention was then turned to the left
infundibulopelvic ligament. It was cauterized using the Omni shear from the Gyrus and it
was cut. This was done along the mesosalpinx to the area of the utero-ovarian ligament.
This was bagged and then sent to pathology for further evaluation. Examination of the
underlying tissues took place and no further bleeding was noted. The irrigation took
place and the patient was cleansed. Thorough examination of all pedicles was performed
and no bleeding was noted. At this time, the lower trocars were removed under direct
visualization and no bleeding was noted. The upper trocar was removed under direct visualization after gas was
allowed to escape from the abdomen. The fascia on the 10 mm incision was easily
identified and closed using a single figure-of-eight suture of 0 Vicryl. All skin
incisions were then closed using subcuticular stitch of 4-0 Vicryl. Sterile Steri-Strips
and a bandage was applied. The patient was cleansed and the remainder of the procedure
was performed by Dr. DeBrakeleer. He did remove the Pratt dilator as well as the Allis.
During my part of the procedure, all sponge and instrument counts times two were correct.
Thanks in advance for your help.
PREOPERATIVE DIAGNOSIS:
1. Retained IUD.
2. Chronic left-sided pelvic pain.
3. Request for permanent sterilization.
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE:
1. IUD retrieval.
2. Diagnostic laparoscopy.
3. Left salpingo-oophorectomy.
4. Lysis of adhesions.
5. Tubal cautery of right fallopian tube.
SURGEON: Dr. Elizabeth Hamilton.
ASSISTANT: Dr. Donald DeBrakaleer
FINDINGS: The uterus was noted to be of normal size, shape, and consistency. No adnexal
masses were grossly appreciated. There was no prolapse noted. The left ovary and tube
appeared within normal limits with some mild round ligament and omental adhesions. The
right fallopian tube and ovary were totally within normal limits. Liver and gallbladder
edge were within normal limits.
COMPLICATIONS: None.
CONDITION: Stable to recovery.
BRIEF SUMMARY: The patient was identified by both the surgeon and anesthesiologist and
brought back to Operating Room #4 where general endotracheal anesthesia was administered.
She was then appropriately placed in the bean bag and placed in the dorsal lithotomy
position. She was prepped and draped in usual sterile fashion. A Foley catheter was
aseptically placed. A bimanual exam was then performed which revealed no adnexal masses
and a normal anteverted size, shape, and consistency to her uterus. At this time, a
breakaway speculum was placed in the vaginal cavity, the cervix easily visualized and
grasped with an Allis clamp. A Pratt dilator was placed in the cervical canal and taped
with sterile Steri-Strips. At this time, gloves were changed and attention was then
turned back to the patient's abdomen. Approximately 5 cc of half percent Marcaine was
injected in a subumbilical portion of skin. This area was elevated with an Allis clamp
and a vertical skin incision was created approximately 5 mm. Veress needle was placed
and the syringe test was performed and noted to be correct. The abdomen was allowed to
fill with approximately 2 liters of CO2 gas when the pressure began to rise. Using a 5 mm
trocar, it was directly inserted under direct visualization. The abdomen and pelvis were
then examined. No underlying injuries were noted. The right and left fallopian tube and
ovary appeared within normal limits. There was noted to be some minimal left round
ligament adhesions. The left omentum was also adhesed to the sidewall. The right ovary
and tube appeared within normal limits. The liver and gallbladder edge appeared within
normal limits. At this time, a second trocar site was chosen in her right lower quadrant.
This was chosen in the area of her C-section scar. It was transilluminated and then
injected with approximately 2.5 cc of half percent Marcaine. A 5 mm skin incision was
created and a 5 mm trocar was directly inserted under direct visualization. The same
procedure was repeated in the left lower quadrant and under direct visualization a 10 mm
trocar was inserted. The right fallopian tube was cauterized using a Kleppinger forceps
until the ammeter read 0 down to the mesosalpinx. Approximately 2 cm portion of tube was
cauterized in its isthmic portion. The left ovary and tube were then examined. The
adhesions in the right round ligament, as well as the omentum were taken down bluntly and
sharply. Hemostasis was noted to be excellent. Attention was then turned to the left
infundibulopelvic ligament. It was cauterized using the Omni shear from the Gyrus and it
was cut. This was done along the mesosalpinx to the area of the utero-ovarian ligament.
This was bagged and then sent to pathology for further evaluation. Examination of the
underlying tissues took place and no further bleeding was noted. The irrigation took
place and the patient was cleansed. Thorough examination of all pedicles was performed
and no bleeding was noted. At this time, the lower trocars were removed under direct
visualization and no bleeding was noted. The upper trocar was removed under direct visualization after gas was
allowed to escape from the abdomen. The fascia on the 10 mm incision was easily
identified and closed using a single figure-of-eight suture of 0 Vicryl. All skin
incisions were then closed using subcuticular stitch of 4-0 Vicryl. Sterile Steri-Strips
and a bandage was applied. The patient was cleansed and the remainder of the procedure
was performed by Dr. DeBrakeleer. He did remove the Pratt dilator as well as the Allis.
During my part of the procedure, all sponge and instrument counts times two were correct.
Thanks in advance for your help.