I'm having a real hard time finding a code for this. The physician went in to do an exploratory laparoscopy and ended up draining an ovarian cyst. So do I code that or the explor lap? I found 58925 but that's an open removal surgery? Any thoughts???
I looked at that but it was for an open procedure- he's already in there laparoscopy and this is what he said he did, "the right ovary demonstrated a small 1cm size ovarian cyst which was unroofed and drained..." that's it. What does 'unroofed' mean? As for the rest of the report, it's pretty much a tour of her pelvis ... what do you think? Would you just code for the exploratory lap procedure instead? Thanks for your help!
Oh Tessa!!! You reminded me of that other OP note that's driving me nuts that's along the same line as this one- the excisional biopsy pf peritoneal nodule on the uterus that I posted earlier today- only that nodule was excised which led me to believe it was 58662. Anyhow, here's this op note-
Patient was brought in to the OR...Abdomen was prepped and draped. A 5mm optiview port was inserted at the umbilicus. Pneumoperitoneum was created with carbon dioxide insufflation. Uterus was normal in appearance, along with both fallopian tubes. The left ovary was unremarkable. The right ovary demonstrated a small 1cm size ovarian cyst which was unroofed and drained. There was no evidence of endometriosis or scar tissue formation. Examinatio of deep pelvis at the peritoneal reflection of rectum showed a small indention to the left side of the rectum on the pelvic sidewall at the level of peritoneal reflexion. It did not appear to be causing any pathologic incarceration or entrapment which would explain pain. No other abnormalities were identified. Ports were withdrawn. No bleeding noted. Skin was closed at all locations...
Tessa, can you look at the other report and see what you think on that one too please?
Jenifer- 58800 is dealing with an ovarian cyst- vaginal approach and 58822 is an ovarian abscess- abdominal approach. Does that help?