I guess I would say, how can they get the specimen and know it's normal without removing?
I kid, I kid. If the procedure is listed in the header but not described in the body of the report, it needs to be sent back to the provider. You can't code it.
What exactly does the report say though? What else was done during the case?
Here the op note. If you don't mind, please share your thought? How should this be coded. Thank you in advance. (I believe I have all the PHI out).
PROCEDURE: Robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic sentinel lymphadenectomy, cystoscopy, and cervical biopsy.
SPECIMENS: Uterus, cervix, ovaries, fallopian tubes, bilateral pelvic sentinel lymph nodes. Left side mapped to the obturator, right side mapped to the external iliac. Frozen section on the uterus and bilateral ovaries showed no evidence of malignant or premalignant disease. Frozen section on the cervical biopsy showed microglandular hyperplasia.
INDICATIONS FOR PROCEDURE: The patient female with a personal history of breast cancer and tamoxifen use. She has had multiple pelvic imaging studies to evaluate the ovaries and endometrial lining. An endometrial curettage by her physician in 07/2022 showed proliferative benign endometrium and polyps. A pelvic ultrasound showed a simple 2 cm left ovarian cyst, microscopic findings on the right ovary, free fluid in the pelvis, and an 11 mm endometrial stripe. I repeated an endometrial biopsy in the office which showed some atypia and markedly degenerated cells. Repeat ultrasound showed an endometrial thickness of 19 mm. There was persistent small amounts of fluid in the posterior cul-de-sac. Lesions were similarly seen on the right and left ovaries. I discussed at length with the patient and her husband over multiple visits risks, benefits, and alternatives of the above procedures. Informed consent was obtained.
FINDINGS:
1. Exam under anesthesia showed a polypoid cervical lesion. This presented at the ectocervix which seemed somewhat dilated. I performed a cervical biopsy and sent this for frozen section which showed no evidence of carcinoma.
2. The uterus was enlarged and 11 mm and bulky.
3. Intra-abdominal findings showed no disease in the upper abdomen. Ovaries with small benign-appearing cysts. Fallopian tubes grossly normal.
4. Pelvic tissues engorged and indurated. More specifically, this was prominent over the bladder flap anteriorly and around the uterine vessels.
5. Sentinel lymph nodes mapped as noted above.
PROCEDURE IN DETAIL: After consent was obtained, the patient was taken to the operating room. She had been asked in the holding area if she had any additional questions and these were answered to her satisfaction. In the operating room, she was placed supine on the table. Venodynes, heparin, and antibiotics were administered. A timeout was performed as per protocol. General anesthesia was induced. She was intubated. Orogastric tube was placed by anesthesia. She was placed in the dorsal lithotomy position and carefully padded to ensure there was no tension in any area of her body. An exam under anesthesia was performed with the above findings noted. She was prepped and draped in a sterile fashion from the nipples down to the upper thighs, including the perineum and the vagina. A latex-free Foley catheter was placed aseptically. The cervix was exposed and grasped with a single-tooth tenaculum. The cervical biopsy was done and sent for frozen section. The results were as noted above. ICG green dye was injected in the cervix as per protocol. The uterine manipulator was placed in standard fashion. A Veress needle was inserted at Palmer's point. A low opening pressure was obtained. The abdomen was easily insufflated with CO2 gas. A 5 mm nonbladed optical trocar was advanced under direct visualization into the abdominal cavity. The abdomen and pelvis was explored with the above findings noted. 8 mm trocars were placed under direct visualization in the right mid and upper quadrant,supraumbilical, and replacing the left upper quadrant trocar. A 12 mm AirSeal was placed in the left lower quadrant. The small bowel was deviated to the upper abdomen. The uterus was placed on gentle upward traction. The robot was docked. Incisions were made lateral and parallel to the IP ligament. The paravesical and pararectal spaces were developed. The uterine arteries were skeletonized. Round ligaments were divided. The sentinel lymph node was identified bilaterally and removed. Bladder flap was sharply developed. The IP ligaments transected with the ureters in full view. Medial leaf of the broad ligament transected down towards the uterosacral. Uterine arteries were skeletonized. As noted in the findings, this area was very indurated and engorged. Bladder flap sharply developed. The uterine arteries transected. The cardinal and uterosacral ligaments transected. Specimen amputated at the cervicovaginal junction and delivered vaginally. Vagina repaired with 9-inch 0 V-Loc suture and a rectovaginal exam was intact and excellent. 3-0 Vicryl on an SH was used to place one Lembert stitch in the peritoneum overlying the dome of the bladder. Cystoscopy was performed with the above findings noted. The robot was undocked. Handheld video laparoscopy was resumed. The left lower quadrant port site was closed at the level of fascia using a Carter-Thomason device. Surgiflo was placed in the dissection bed. All instruments were removed. The count was correct. The skin was closed with 4-0 Monocryl and Dermabond. The patient was awakened and taken to recovery room in stable condition. I discussed these findings with her husband at her request.