Good morning, I'm hoping to get advice on a GYN surgery. The provider wants to code a 58554 (LAVH) and the coder wants to code 57573 (TLH) and I'm thinking it might be a 58150 but would like some advice.
In his note.... he states the following - Due to the large uterus specimen that could not be removed through the narrow vagina the decision was made to extract the uterus from the abdomen through a minilaparotomy incision after closure of the vaginal cuff. We subsequently proceeded with an introduction of V-loc barbed suturing in a running fashion from right to left and left to right including this 2nd layer the bladder flap....Then we made a 6-cm transverse incision on the previous phannensteil scar.....Subsequently the uterus specimen identified and removed through the minilaparotomy without difficulty.
No where does he state removing the trocars either. I've attached a portion of the operative note.
Can I get some opinions on this.
Greatly appreciated
In his note.... he states the following - Due to the large uterus specimen that could not be removed through the narrow vagina the decision was made to extract the uterus from the abdomen through a minilaparotomy incision after closure of the vaginal cuff. We subsequently proceeded with an introduction of V-loc barbed suturing in a running fashion from right to left and left to right including this 2nd layer the bladder flap....Then we made a 6-cm transverse incision on the previous phannensteil scar.....Subsequently the uterus specimen identified and removed through the minilaparotomy without difficulty.
No where does he state removing the trocars either. I've attached a portion of the operative note.
Can I get some opinions on this.
Greatly appreciated