Hi, my question(s) with regard to the below note is primarily with regard to the highlighted section. The doctor is billing both 57250 and 57283, which don't bundle; I understand they can both be billed, but I don't see what the distinction is for one vs the other in the below documentation since they both involve the levator muscle. I have been unable to find anything to help me clarify. Are both documented there?
Post-Op Diagnosis:
1. Stage III vaginal vault prolapse after hysterectomy [N99.3]
2. Nocturia [R35.1]
3. Enterocele
Procedure:
Colpocleisis with complete colpectomy, vaginal enterocele repair, posterior colporrhaphy, perineorrhaphy, cystoscopy
Anesthesia Type: General
Complications: None
Indication:xxx is a 70yo with symptomatic stage III anterior predominant pelvic organ prolapse. She had previously tried a pessary but found this to be uncomfortable and bothersome. She made the decision to move forward with surgical management with an obliterative surgical procedure after understanding the risks/benefits/alternatives. She did not desire future vaginally penetrative intercourse. Preoperative urodynamic testing did not demonstrate any evidence of urodynamic stress incontinence with or without prolapse reduction. Therefore we decided to not perform a concomitant mid urethral sling. Patient understands the risks of potential occult stress incontinence.
Findings:
1. Normal external female genitalia with atrophy noted. Stage III anterior predominant pelvic organ prolapse consistent with in office exam.
2. Procedure was performed with excellent reduction of the prolapse and excellent hemostasis.
3. Cystoscopy performed with no evidence of foreign body or injury. Ureteral orifices were orthotopic and brisk bilateral ureteral efflux visualized indicating patency. Multiple prominent trabeculations noted. No lesions, ulcerations, tumors, petechiae, diverticulum.
Description: The patient was identified in the holding area, and informed consent was obtained. She was taken back to the operating room, where an adequate level of general anesthesia was obtained. Intravenous antibiotics were given preoperatively and SCDs were placed on her lower extremities. She was intubated. She was placed in high dorsal lithotomy position with careful attention paid to leg positioning to ensure there was no hyperextension or hyperflexion of her joints to avoid muscular or neurological damage. Exam under anesthesia was performed with the findings as noted above. The patient's vagina and perineum were prepped and draped in the usual sterile fashion. A surgical time-out was completed in which the patient as well as the procedure was identified and confirmed. A foley catheter was placed.
A Lone Star retractor was used for adequate visualization and retraction. After injection of dilute vasopressin, the vaginal epithelium was sharply dissected off of the entire anterior and posterior vagina. The entire vaginal epithelium, from apex to hymen, and in full thickness down to underlying tissue was removed. Hemostasis was achieved using minimal electrocautery. There was an enterocele sac and peritoneal defect noted at the posterior aspect of the vaginal apex. This was entered and closed with a 2-0 Vicryl suture in a running fashion. Then serial pursestring sutures using 2-0 PDS were placed through the anterior and posterior endopelvic fascia to reduce the vagina inward. There was still minimal bleeding noted. FloSeal was applied and pressure was applied, which achieved excellent hemostasis. 2-0 Vicryl suture was used to close the vaginal epithelium in a running fashion.
We then turned our attention to the posterior repair and perineorrhaphy. Two Allis clamps were placed on the hymenal remnants laterally. Vasopressin was injected. A scalpel was used to excise a diamond shaped piece of vaginal epithelium and skin overlying the perineum. Sharp dissection was performed using the Metzenbaum scissors to dissect the epithelium off of the underlying rectovaginal fibromuscular connective tissue and the perineal muscles. A levator plication and perineorrhaphy was performed using 2-0 PDS suture to plicate the rectovaginal fibromuscular connective tissue and the levator muscles and transverse perieni muscles in the midline. The epithelium and skin were then closed with a 2-0 Vicryl suture in a running subcuticular fashion. Hemostasis was excellent.
Cystoscopy was then performed after removing the Foley catheter using a 70 degree cystoscope with a 17 French sheath. The bladder was exam and completely. There were moderate trabeculations noted but no other abnormalities. There was brisk bilateral ureteral flow, indicating ureteral patency. The cystoscope was removed and the Foley catheter was replaced.
All instruments were removed from the vagina. There was excellent hemostasis. Counts were correct x2. The patient was taken out of dorsal lithotomy position. The patient tolerated the procedure well. There were no complications.
Lay description
57250 - After administering regional or general anesthesia, the surgeon inserts a speculum into the vagina to hold it open during the procedure. He then performs a rectal exam to check for the extent of the rectocele. He makes an incision in the posterior vaginal wall from the top of the vagina to the levator muscles. He plicates the fascia and brings the edges together and sutures them, making sure that some of the levator muscle is included in the repair. He removes excess vaginal wall tissue. When the provider performs perineorrhaphy, he also repairs the levator and perineal muscles. The provider then adds vaginal packing.
57283 = The provider administers anesthesia and appropriately preps and drapes the patient. In an intraperitoneal vaginal vault suspension, the provider opens the vaginal mucosa at the apex of the vagina. He dissects away the pubocervical and rectovaginal fascia from the vaginal wall, which exposes the enterocele. He identifies the peritoneum and sharply enters it. He retracts the bowel away and packs it with a laparotomy towel. The provider identifies the ureters and palpates them bilaterally because they come very close to the uterosacral ligament, and the physician wants to be sure he does not suture the ureters. He identifies the uterosacral ligaments on each side. He grasps the uterosacral ligaments with clamps and places them on traction. He then places a series of interrupted sutures through the uterosacral ligaments on both sides and pulls them together to plicate the ligaments. At this point, he places sutures into the top of the anterior and posterior vaginal walls and anchors them into the plicated uterosacral ligaments. If the provider instead uses the levator muscle, he places sutures into this structure to create a shelf above the rectum. He then ties sutures from the vaginal vault into this shelf for support. He performs culdoplasty to obliterate the cul–de–sac, or enterocele. He brings the sutures through the exposed pubocervical and rectovaginal fascia. He then ties the sutures to suspend the vagina deep in the pelvis. He closes the vaginal vault with interrupted sutures. He then places a Foley catheter for bladder drainage and packs the vagina with gauze.
Post-Op Diagnosis:
1. Stage III vaginal vault prolapse after hysterectomy [N99.3]
2. Nocturia [R35.1]
3. Enterocele
Procedure:
Colpocleisis with complete colpectomy, vaginal enterocele repair, posterior colporrhaphy, perineorrhaphy, cystoscopy
Anesthesia Type: General
Complications: None
Indication:xxx is a 70yo with symptomatic stage III anterior predominant pelvic organ prolapse. She had previously tried a pessary but found this to be uncomfortable and bothersome. She made the decision to move forward with surgical management with an obliterative surgical procedure after understanding the risks/benefits/alternatives. She did not desire future vaginally penetrative intercourse. Preoperative urodynamic testing did not demonstrate any evidence of urodynamic stress incontinence with or without prolapse reduction. Therefore we decided to not perform a concomitant mid urethral sling. Patient understands the risks of potential occult stress incontinence.
Findings:
1. Normal external female genitalia with atrophy noted. Stage III anterior predominant pelvic organ prolapse consistent with in office exam.
2. Procedure was performed with excellent reduction of the prolapse and excellent hemostasis.
3. Cystoscopy performed with no evidence of foreign body or injury. Ureteral orifices were orthotopic and brisk bilateral ureteral efflux visualized indicating patency. Multiple prominent trabeculations noted. No lesions, ulcerations, tumors, petechiae, diverticulum.
Description: The patient was identified in the holding area, and informed consent was obtained. She was taken back to the operating room, where an adequate level of general anesthesia was obtained. Intravenous antibiotics were given preoperatively and SCDs were placed on her lower extremities. She was intubated. She was placed in high dorsal lithotomy position with careful attention paid to leg positioning to ensure there was no hyperextension or hyperflexion of her joints to avoid muscular or neurological damage. Exam under anesthesia was performed with the findings as noted above. The patient's vagina and perineum were prepped and draped in the usual sterile fashion. A surgical time-out was completed in which the patient as well as the procedure was identified and confirmed. A foley catheter was placed.
A Lone Star retractor was used for adequate visualization and retraction. After injection of dilute vasopressin, the vaginal epithelium was sharply dissected off of the entire anterior and posterior vagina. The entire vaginal epithelium, from apex to hymen, and in full thickness down to underlying tissue was removed. Hemostasis was achieved using minimal electrocautery. There was an enterocele sac and peritoneal defect noted at the posterior aspect of the vaginal apex. This was entered and closed with a 2-0 Vicryl suture in a running fashion. Then serial pursestring sutures using 2-0 PDS were placed through the anterior and posterior endopelvic fascia to reduce the vagina inward. There was still minimal bleeding noted. FloSeal was applied and pressure was applied, which achieved excellent hemostasis. 2-0 Vicryl suture was used to close the vaginal epithelium in a running fashion.
We then turned our attention to the posterior repair and perineorrhaphy. Two Allis clamps were placed on the hymenal remnants laterally. Vasopressin was injected. A scalpel was used to excise a diamond shaped piece of vaginal epithelium and skin overlying the perineum. Sharp dissection was performed using the Metzenbaum scissors to dissect the epithelium off of the underlying rectovaginal fibromuscular connective tissue and the perineal muscles. A levator plication and perineorrhaphy was performed using 2-0 PDS suture to plicate the rectovaginal fibromuscular connective tissue and the levator muscles and transverse perieni muscles in the midline. The epithelium and skin were then closed with a 2-0 Vicryl suture in a running subcuticular fashion. Hemostasis was excellent.
Cystoscopy was then performed after removing the Foley catheter using a 70 degree cystoscope with a 17 French sheath. The bladder was exam and completely. There were moderate trabeculations noted but no other abnormalities. There was brisk bilateral ureteral flow, indicating ureteral patency. The cystoscope was removed and the Foley catheter was replaced.
All instruments were removed from the vagina. There was excellent hemostasis. Counts were correct x2. The patient was taken out of dorsal lithotomy position. The patient tolerated the procedure well. There were no complications.
Lay description
57250 - After administering regional or general anesthesia, the surgeon inserts a speculum into the vagina to hold it open during the procedure. He then performs a rectal exam to check for the extent of the rectocele. He makes an incision in the posterior vaginal wall from the top of the vagina to the levator muscles. He plicates the fascia and brings the edges together and sutures them, making sure that some of the levator muscle is included in the repair. He removes excess vaginal wall tissue. When the provider performs perineorrhaphy, he also repairs the levator and perineal muscles. The provider then adds vaginal packing.
57283 = The provider administers anesthesia and appropriately preps and drapes the patient. In an intraperitoneal vaginal vault suspension, the provider opens the vaginal mucosa at the apex of the vagina. He dissects away the pubocervical and rectovaginal fascia from the vaginal wall, which exposes the enterocele. He identifies the peritoneum and sharply enters it. He retracts the bowel away and packs it with a laparotomy towel. The provider identifies the ureters and palpates them bilaterally because they come very close to the uterosacral ligament, and the physician wants to be sure he does not suture the ureters. He identifies the uterosacral ligaments on each side. He grasps the uterosacral ligaments with clamps and places them on traction. He then places a series of interrupted sutures through the uterosacral ligaments on both sides and pulls them together to plicate the ligaments. At this point, he places sutures into the top of the anterior and posterior vaginal walls and anchors them into the plicated uterosacral ligaments. If the provider instead uses the levator muscle, he places sutures into this structure to create a shelf above the rectum. He then ties sutures from the vaginal vault into this shelf for support. He performs culdoplasty to obliterate the cul–de–sac, or enterocele. He brings the sutures through the exposed pubocervical and rectovaginal fascia. He then ties the sutures to suspend the vagina deep in the pelvis. He closes the vaginal vault with interrupted sutures. He then places a Foley catheter for bladder drainage and packs the vagina with gauze.