debellis59
Networker
Hi All:
I have a provider that did what was supposed to be an exploratory laparoscopy. But, she ran into extensive adhesions between the uterus and the abdominal wall. The note is below. I'm confounded on how to code this. I am coming up with the unlisted code 49329. I've been told that the doc believes it should be 58660, but there is no mention of adhesions to the ovaries or fallopian tubes. What would your suggestions and expertise have to say on the coding for this? I really appreciate any and all suggestions. I can see where the 58660 would be a go to code for approximate cost of the procedure. Thank you!!!
DESCRIPTION OF OPERATION: Upon induction of excellent general endotracheal anesthesia, the patient was prepped and draped in the dorsal lithotomy position. Bimanual examination revealed the uterus to be anteverted and normal size with no adnexal masses palpable. A sponge stick was used for manipulation. The patient’s bladder was decompressed with straight gravity drainage.
Attention was then turned to the patient's abdomen where a small infraumbilical incision was made with scalpel. Veress needle was placed through this incision and the patient's abdomen was inflated to a pressure of 15 mmHg. Veress needle was removed and then 5-mm bariatric trocar was placed through the umbilical incision. Laparoscope was placed through this incision and the patient's abdominal contents were visualized. A 2nd and 3rd trocar incision was placed in the in the right and left lower quadrants. A 5-mm trocar was placed through these incisions on direct visualization with the laparoscope.
Operative finding noted the thick adhesive disease between uterus and anterior abdominal wall. The Ligasure was used along with cautery to lyse the adhesions. Careful attention was taken to make sure to respect the anterior abdominal wall, to avoid entering fascia and not enter the uterine cavity. The adhesion lysis took greater than 30 mins. At the completion, the anterior abdominal wall surveyed and fascia was not compromised. The uterus was evaluated and with the use of cautery and Arista hemostasis was obtained.
The procedure was then completed. The trocars were removed. Closure was then accomplished with 4-0 Vicryl on the skin. Hemostasis was observed.
I have a provider that did what was supposed to be an exploratory laparoscopy. But, she ran into extensive adhesions between the uterus and the abdominal wall. The note is below. I'm confounded on how to code this. I am coming up with the unlisted code 49329. I've been told that the doc believes it should be 58660, but there is no mention of adhesions to the ovaries or fallopian tubes. What would your suggestions and expertise have to say on the coding for this? I really appreciate any and all suggestions. I can see where the 58660 would be a go to code for approximate cost of the procedure. Thank you!!!
DESCRIPTION OF OPERATION: Upon induction of excellent general endotracheal anesthesia, the patient was prepped and draped in the dorsal lithotomy position. Bimanual examination revealed the uterus to be anteverted and normal size with no adnexal masses palpable. A sponge stick was used for manipulation. The patient’s bladder was decompressed with straight gravity drainage.
Attention was then turned to the patient's abdomen where a small infraumbilical incision was made with scalpel. Veress needle was placed through this incision and the patient's abdomen was inflated to a pressure of 15 mmHg. Veress needle was removed and then 5-mm bariatric trocar was placed through the umbilical incision. Laparoscope was placed through this incision and the patient's abdominal contents were visualized. A 2nd and 3rd trocar incision was placed in the in the right and left lower quadrants. A 5-mm trocar was placed through these incisions on direct visualization with the laparoscope.
Operative finding noted the thick adhesive disease between uterus and anterior abdominal wall. The Ligasure was used along with cautery to lyse the adhesions. Careful attention was taken to make sure to respect the anterior abdominal wall, to avoid entering fascia and not enter the uterine cavity. The adhesion lysis took greater than 30 mins. At the completion, the anterior abdominal wall surveyed and fascia was not compromised. The uterus was evaluated and with the use of cautery and Arista hemostasis was obtained.
The procedure was then completed. The trocars were removed. Closure was then accomplished with 4-0 Vicryl on the skin. Hemostasis was observed.