SLELISON
Guest
I am not familiar with OB/GYN 
Someone please help me with this op note. Can I bill 58662 with 58671? Also what dx would be used? Thanks in advance for any guidence!!!
PREOPERATIVE DIAGNOSIS: Desire for permanent sterilization.
POSTOPERATIVE DIAGNOSIS: Desire for permanent sterilization, release of internal hernia and removal of fimbrial pedunculated cyst.
PROCEDURE PERFORMED: lap tubal and release internal hernia and removal pedunculated fibroid cyst all laparoscopic.
DESCRIPTION OF THE PROCEDURE: After the risks, benefits, complications, and possible sequela were discussed with the patient, verbal and written consent were obtained. The patient was taken to the OR by Anesthesia undergoing a general anesthetic. The abdomen was sterilely prepped and draped, Foley catheter having been previously inserted after which 0.25% Marcaine with epinephrine was used to obtain peri-incisional anesthesia. Incision was made in the umbilicus. A 5 mm bladeless port was placed into the abdominal cavity insufflating the abdomen to 15 mmHg with CO2 gas. Under direct visualization, a 12 mm port was placed in the suprapubic region through a previous C-section scar. We identified a pedunculated cyst at the right fimbria. This was removed with cautery at the base to obtain hemostasis with scissor resection. The specimen was not sent for pathologic evaluation. We then traced out the right fimbria and placed two clips proximally on the right fallopian tube and two clips distally on the right fallopian tube and divided between this with scissor cautery cauterizing the proximal and distal ends of the right fallopian tube.
Attention was then turned to the left side where the fallopian tube was traced down the left fimbria and two proximal clips were placed and two distal clips on the left fallopian tube were placed after which the fallopian tube was divided with scissor cautery and the proximal and distal ends were also cauterized. The remaining portion of the case was devoted to gross inspection of the intra-abdominal contents. The gallbladder, bowel, liver, stomach, intestines, and uterus all appeared to be normal except for a portion of the omentum, which was adherent to the right lateral portion of the bladder. Utilizing careful scissor dissection, this was removed preventing an internal hernia from forming as there was a window laterally and medially to the adherent omentum. Hemostasis was excellent. Utilization of a clip applier was justified at one point secondary to a small oozer present in the ometum that was not controlled with the application of cautery. Verifying hemostasis from all operative sites within the abdomen and pelvis, we then removed our trocars verifying hemostasis from the port site and allowed the gas to escape from the abdominal cavity and the 12 mm port site was closed in the fascial layer with 0 Vicryl and 4-0 Monocryl was used to close the skin in both incisions. Sterile dressings were placed. The patient was awakened from anesthesia and taken to the recovery room in stable condition with no apparent complications.
Someone please help me with this op note. Can I bill 58662 with 58671? Also what dx would be used? Thanks in advance for any guidence!!! PREOPERATIVE DIAGNOSIS: Desire for permanent sterilization.
POSTOPERATIVE DIAGNOSIS: Desire for permanent sterilization, release of internal hernia and removal of fimbrial pedunculated cyst.
PROCEDURE PERFORMED: lap tubal and release internal hernia and removal pedunculated fibroid cyst all laparoscopic.
DESCRIPTION OF THE PROCEDURE: After the risks, benefits, complications, and possible sequela were discussed with the patient, verbal and written consent were obtained. The patient was taken to the OR by Anesthesia undergoing a general anesthetic. The abdomen was sterilely prepped and draped, Foley catheter having been previously inserted after which 0.25% Marcaine with epinephrine was used to obtain peri-incisional anesthesia. Incision was made in the umbilicus. A 5 mm bladeless port was placed into the abdominal cavity insufflating the abdomen to 15 mmHg with CO2 gas. Under direct visualization, a 12 mm port was placed in the suprapubic region through a previous C-section scar. We identified a pedunculated cyst at the right fimbria. This was removed with cautery at the base to obtain hemostasis with scissor resection. The specimen was not sent for pathologic evaluation. We then traced out the right fimbria and placed two clips proximally on the right fallopian tube and two clips distally on the right fallopian tube and divided between this with scissor cautery cauterizing the proximal and distal ends of the right fallopian tube.
Attention was then turned to the left side where the fallopian tube was traced down the left fimbria and two proximal clips were placed and two distal clips on the left fallopian tube were placed after which the fallopian tube was divided with scissor cautery and the proximal and distal ends were also cauterized. The remaining portion of the case was devoted to gross inspection of the intra-abdominal contents. The gallbladder, bowel, liver, stomach, intestines, and uterus all appeared to be normal except for a portion of the omentum, which was adherent to the right lateral portion of the bladder. Utilizing careful scissor dissection, this was removed preventing an internal hernia from forming as there was a window laterally and medially to the adherent omentum. Hemostasis was excellent. Utilization of a clip applier was justified at one point secondary to a small oozer present in the ometum that was not controlled with the application of cautery. Verifying hemostasis from all operative sites within the abdomen and pelvis, we then removed our trocars verifying hemostasis from the port site and allowed the gas to escape from the abdominal cavity and the 12 mm port site was closed in the fascial layer with 0 Vicryl and 4-0 Monocryl was used to close the skin in both incisions. Sterile dressings were placed. The patient was awakened from anesthesia and taken to the recovery room in stable condition with no apparent complications.