Wiki OP NOTE CPT CODING

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bag4498

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We have one physician who never states in the description of the OP note that he is removing ovaries/tubes with the uterus. However, he does state it like this:

PROCEDURE PERFORMED: Robotic-assisted laparoscopic supracervical hysterectomy
with bilateral salpingo-oophorectomy
PATHOLOGY: Supracervical uterus, bilateral tubes and ovaries sent for final
pathology

I would like some opinions from coders on how would you code this? would you code it as just a hysterectomy 58541, a hysterectomy with removal of 58542 or would you send a query because its not documented in the body of the OP note?

Thanks
 
Could you post a reacted example of an op note? Is he maybe saying it without saying those specific words?
 
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