lindacoder
Guest
Preop diagnosis: Laparoscopic assisted vaginal hystrectomy - questionable serosal tear of the rectum.
Post-op diagnosis - no abnormality.
Procedure: Rigid sigmoidoscope.
Procedure: Dr. Smith did a laparascopic assisted vaginal hysterectomy. As they were freeing things up, it was somewhat stuck down sort of to the peritoneum and onto the rectum. She was concerned with possible serosal tear. I therefore came in to look at the area. On exam, it still actually just seems to be a very superficial layer: really does not even, more of a peritoneal attachment. To be safe however, I did go ahead and proceed on with a rigid sigmoidoscopy. I placced the sigmoidoscope into the anal verge. We put water over the area of concern. I looked up to this area; it looked good. Mucosa was intact and we saw no signs of air bubbling. The air was then removed. She tolerated the pocedure well.
I need help with CPT and ICD-9 please.
Thanks
Post-op diagnosis - no abnormality.
Procedure: Rigid sigmoidoscope.
Procedure: Dr. Smith did a laparascopic assisted vaginal hysterectomy. As they were freeing things up, it was somewhat stuck down sort of to the peritoneum and onto the rectum. She was concerned with possible serosal tear. I therefore came in to look at the area. On exam, it still actually just seems to be a very superficial layer: really does not even, more of a peritoneal attachment. To be safe however, I did go ahead and proceed on with a rigid sigmoidoscopy. I placced the sigmoidoscope into the anal verge. We put water over the area of concern. I looked up to this area; it looked good. Mucosa was intact and we saw no signs of air bubbling. The air was then removed. She tolerated the pocedure well.
I need help with CPT and ICD-9 please.
Thanks