Korbc
Expert
Hey guys!
Would i just do 58561 one for this one or should another code be used with 58561 because prior to her inserting the h'scope she cored out the fibroid which was separate than the location and method of the rest of the removal?
thanks so much!
Description of Procedure: The patient was taken to the operating room. General anesthesia with an LMA was administered without difficulty. She was prepped and draped in the usual sterile fashion in the dorsal lithotomy position with her legs in allen stirrups. The bladder was straight catheterized.
A surgical pause was performed. A speculum was placed, and the mass was able to be visualized and palpated prolapsing through the cervix into the vagina. The stalk was broad based, about 2cm. The mass/fibroid was grasped with a tenaculum. The stalk was tied off with a free tie suture. The fibroid was then cored out until it was resected to the suture. The hysteroscope was inserted and then clamped shut around the camera with allis clamps. There was noted to be a long wide stalk from the fibroid attached to the fundus. There was also some separate polyps and some thickened endometrium in one area. The myosure was used to resect all of this. All tissue was sent to pathology.
All instruments were removed. The cervix was hemostatic. The patient was awakened and transferred to recovery in stable condition.
Would i just do 58561 one for this one or should another code be used with 58561 because prior to her inserting the h'scope she cored out the fibroid which was separate than the location and method of the rest of the removal?
thanks so much!
Description of Procedure: The patient was taken to the operating room. General anesthesia with an LMA was administered without difficulty. She was prepped and draped in the usual sterile fashion in the dorsal lithotomy position with her legs in allen stirrups. The bladder was straight catheterized.
A surgical pause was performed. A speculum was placed, and the mass was able to be visualized and palpated prolapsing through the cervix into the vagina. The stalk was broad based, about 2cm. The mass/fibroid was grasped with a tenaculum. The stalk was tied off with a free tie suture. The fibroid was then cored out until it was resected to the suture. The hysteroscope was inserted and then clamped shut around the camera with allis clamps. There was noted to be a long wide stalk from the fibroid attached to the fundus. There was also some separate polyps and some thickened endometrium in one area. The myosure was used to resect all of this. All tissue was sent to pathology.
All instruments were removed. The cervix was hemostatic. The patient was awakened and transferred to recovery in stable condition.