monicahkfan
Networker
Here is the op note. Provider is billing 57061.
PROCEDURES:
1. Wide local excision of vaginal intraepithelial neoplasia 2 (VAIN 2),
bilateral fornices.
2. Laser brushing of vaginal mucosa.
FINDINGS AT THE TIME OF SURGERY: Atrophic vaginal mucosa. Bilateral
fornices areas of acetyl white staining with previous biopsy noted.
PROCEDURE DESCRIPTION: The patient was taken to the OR and placed in the
supine position. Two patient identifiers and the procedure were confirmed.
The patient was then administered general anesthesia. After adequate
anesthesia was assured, the patient was placed in the dorsal lithotomy
position and examination under anesthesia was performed. The vagina was
then prepped and draped in a sterile manner with Betadine, and the bladder
emptied with a red rubber catheter. A sponge stick then soaked with a
dilute solution of acetic acid was placed into the vagina. This was left
in place for approximately 3-4 minutes and using the colposcope, the
vaginal mucosa was inspected. There were areas of acetyl white staining in
the bilateral fornices, and marked atrophy of the vaginal vault was noted.
At this point then, the area of acetyl white staining was marked with a
marking pen and then using a spinal needle, 0.25% Marcaine was infiltrated
beneath the mucosa of bilateral fornices. Once this was accomplished, the
CO2 laser was hooked to the colposcope, and laser brushing of the vaginal
mucosa was accomplished using 4 watts of power on continuous pulse. Once
this was accomplished, the laser was disconnected and using Metzenbaum
scissors, the bilateral fornices mucosa was dissected free. The mucosal
edges were then reapproximated with 3-0 Vicryl in a running locking stitch
bilaterally. There was minimal bleeding noted. All sponge and instrument
counts were correct. Silvadene was then applied to the vaginal vault. The
patient was then transferred to the recovery room in satisfactory
condition. All sponge and instrument counts were correct. There were no
grafts left or placed, and there was no assistant for the surgery.
Any ideas??
PROCEDURES:
1. Wide local excision of vaginal intraepithelial neoplasia 2 (VAIN 2),
bilateral fornices.
2. Laser brushing of vaginal mucosa.
FINDINGS AT THE TIME OF SURGERY: Atrophic vaginal mucosa. Bilateral
fornices areas of acetyl white staining with previous biopsy noted.
PROCEDURE DESCRIPTION: The patient was taken to the OR and placed in the
supine position. Two patient identifiers and the procedure were confirmed.
The patient was then administered general anesthesia. After adequate
anesthesia was assured, the patient was placed in the dorsal lithotomy
position and examination under anesthesia was performed. The vagina was
then prepped and draped in a sterile manner with Betadine, and the bladder
emptied with a red rubber catheter. A sponge stick then soaked with a
dilute solution of acetic acid was placed into the vagina. This was left
in place for approximately 3-4 minutes and using the colposcope, the
vaginal mucosa was inspected. There were areas of acetyl white staining in
the bilateral fornices, and marked atrophy of the vaginal vault was noted.
At this point then, the area of acetyl white staining was marked with a
marking pen and then using a spinal needle, 0.25% Marcaine was infiltrated
beneath the mucosa of bilateral fornices. Once this was accomplished, the
CO2 laser was hooked to the colposcope, and laser brushing of the vaginal
mucosa was accomplished using 4 watts of power on continuous pulse. Once
this was accomplished, the laser was disconnected and using Metzenbaum
scissors, the bilateral fornices mucosa was dissected free. The mucosal
edges were then reapproximated with 3-0 Vicryl in a running locking stitch
bilaterally. There was minimal bleeding noted. All sponge and instrument
counts were correct. Silvadene was then applied to the vaginal vault. The
patient was then transferred to the recovery room in satisfactory
condition. All sponge and instrument counts were correct. There were no
grafts left or placed, and there was no assistant for the surgery.
Any ideas??