trose45116
Expert
hi,
would you code the fulgration of the endometrial implants and if so what code would you use. ive highlighted in red. thanks
PREOPERATIVE DIAGNOSIS: Endometrial polyp.
POSTOPERATIVE DIAGNOSES: Lower segment endocervical polyp and cervical
endometriosis.
PROCEDURES PERFORMED: 1. Operative hysteroscopy with polypectomy
and endometrial biopsy.
2. Fulguration of cervical endometriosis
implants.
OPERATIVE FINDINGS: Exam under anesthesia revealed the uterus is in slightly mid to retroverted
position, deviated to right and normal size, shape, movable and regular. Right adnexa was free and the left
adnexa was free. There was some thickening noted in the posterior left cul-de-sac.
On visualization of the uterine and endometrial cavity, both tubal ostia were visualized and appeared
normal, and the endometrial cavity appeared normal. There was a small area of polypoid area noted in the
lower uterine segment and a pedunculated polyp was noted in the upper endocervical canal. Rest of the
endometrial cavity appeared normal.
There was superficial endometriosis implants noted on the portio of the cervix at 3 o’clock and from 10 to
1 o’clock position and then at 6 o’clock position.
OPERATIVE PROCEDURE: After the patient had general anesthesia induced by LMA, she was
placed in modified lithotomy position using Smith-Allen stirrups to avoid any pressure points. The
perineum and vagina were prepped and a Foley catheter was placed after usual sterile prepping and
draping and bimanual exam revealed the findings as mentioned above.
Then, the surgeon proceeded with the procedure.
A bivalved open-ended speculum was positioned. The cervix was held with a tenaculum clamp. We
attempted to pass a small Hanks dilator. There was some resistance noted in the endocervical canal, so in
order to avoid creation of a false passage, I used a diagnostic hysteroscope and used Smith & Nephew
Medtronic fluid management system and normal saline to distend the endometrial cavity. So using the
diagnostic hysteroscope, hysteroscopy procedure was carried out and the internal os location was noted.
Under direct vision, the hysteroscope was advanced into the endometrial cavity. The findings were as
mentioned above. At this stage, diagnostic hysteroscope was removed and the cervix dilated with Hanks
dilator to #14. Then, we used a Gynecare SlimLine operative hysteroscope and normal saline for
distention medium, the hysteroscopy procedure was carried out. Using a hysteroscope for this, the polyp
in the endocervical canal was excised and the polypoid area in the lower uterine posterior segment was
excised. These specimens were collected. All the fluids used during hysteroscopy were accounted for.
There was no active bleeding observed. We used 1220 cc of normal saline and then 620 cc was suctioned
out. There was a deficit of 600 cc.
Following the hysteroscopy procedure using a small curette, endometrial biopsy was obtained.
Using a monopolar Bovie with a coagulation current at 20 to 30 watts and using the needle tip Bovie, the
endometriosis implants and the portio of the cervix were fulgurated. Blood loss during the procedure was
5 cc and clear urine was noted in the Foley bag. The urine output was 600 cc. Specimen consisted of
endocervical polyp and endometrial biopsy. The patient tolerated the procedure well and transferred to the
recovery room in good condition.
would you code the fulgration of the endometrial implants and if so what code would you use. ive highlighted in red. thanks
PREOPERATIVE DIAGNOSIS: Endometrial polyp.
POSTOPERATIVE DIAGNOSES: Lower segment endocervical polyp and cervical
endometriosis.
PROCEDURES PERFORMED: 1. Operative hysteroscopy with polypectomy
and endometrial biopsy.
2. Fulguration of cervical endometriosis
implants.
OPERATIVE FINDINGS: Exam under anesthesia revealed the uterus is in slightly mid to retroverted
position, deviated to right and normal size, shape, movable and regular. Right adnexa was free and the left
adnexa was free. There was some thickening noted in the posterior left cul-de-sac.
On visualization of the uterine and endometrial cavity, both tubal ostia were visualized and appeared
normal, and the endometrial cavity appeared normal. There was a small area of polypoid area noted in the
lower uterine segment and a pedunculated polyp was noted in the upper endocervical canal. Rest of the
endometrial cavity appeared normal.
There was superficial endometriosis implants noted on the portio of the cervix at 3 o’clock and from 10 to
1 o’clock position and then at 6 o’clock position.
OPERATIVE PROCEDURE: After the patient had general anesthesia induced by LMA, she was
placed in modified lithotomy position using Smith-Allen stirrups to avoid any pressure points. The
perineum and vagina were prepped and a Foley catheter was placed after usual sterile prepping and
draping and bimanual exam revealed the findings as mentioned above.
Then, the surgeon proceeded with the procedure.
A bivalved open-ended speculum was positioned. The cervix was held with a tenaculum clamp. We
attempted to pass a small Hanks dilator. There was some resistance noted in the endocervical canal, so in
order to avoid creation of a false passage, I used a diagnostic hysteroscope and used Smith & Nephew
Medtronic fluid management system and normal saline to distend the endometrial cavity. So using the
diagnostic hysteroscope, hysteroscopy procedure was carried out and the internal os location was noted.
Under direct vision, the hysteroscope was advanced into the endometrial cavity. The findings were as
mentioned above. At this stage, diagnostic hysteroscope was removed and the cervix dilated with Hanks
dilator to #14. Then, we used a Gynecare SlimLine operative hysteroscope and normal saline for
distention medium, the hysteroscopy procedure was carried out. Using a hysteroscope for this, the polyp
in the endocervical canal was excised and the polypoid area in the lower uterine posterior segment was
excised. These specimens were collected. All the fluids used during hysteroscopy were accounted for.
There was no active bleeding observed. We used 1220 cc of normal saline and then 620 cc was suctioned
out. There was a deficit of 600 cc.
Following the hysteroscopy procedure using a small curette, endometrial biopsy was obtained.
Using a monopolar Bovie with a coagulation current at 20 to 30 watts and using the needle tip Bovie, the
endometriosis implants and the portio of the cervix were fulgurated. Blood loss during the procedure was
5 cc and clear urine was noted in the Foley bag. The urine output was 600 cc. Specimen consisted of
endocervical polyp and endometrial biopsy. The patient tolerated the procedure well and transferred to the
recovery room in good condition.