Can't decide which code- 57250 or 45560- can someone please help me understand what surgery he did exactly? From the descriptions of the surgeries, it sounds like 57250 but I'm not sure...
Here's the OP note:
...she was positioned in the dorsal lithotomy position. The vagina and perineum were prepped and draped in sterile fashion. The labia was retracted to the side with 2-0 silk stitch on each side. Foley catheter was sterilely inserted at the start of the case. The rectocele was visualized bulging up under the posterior vaginal wall. The vaginal mucosa was grasped with Allis forcep and incised in the midline. A vascular plane was developed between the rectocele tissue and the vaginal wall. This plane was developed out to the sides where the lateral pelvic fascia and levator muscles were identified. The levator was somewhat diminutive in size. Superiorly the vaginal vault was foreshortened due to previous hysterectomy. Care was taken not to extend the incision up onto the apex of the vagina and cause any more shortening. Once the rectocele was completely dissected out and the lateral attachment points for the sutures were clearly visualized, the lateral pelvic fascia and levator muscles were approximated in the midline with interrupted figure of eight sutures. Once this was completed and maintained reduction of the rectocele, the excess vaginal wall in the posterior aspect was removed sharply and then closed in the midline with running 3-0 chromic. Digital rectal exam revealed no persistence of the rectocele and good construction of the rectovaginal septum...
any thoughts out there?
Here's the OP note:
...she was positioned in the dorsal lithotomy position. The vagina and perineum were prepped and draped in sterile fashion. The labia was retracted to the side with 2-0 silk stitch on each side. Foley catheter was sterilely inserted at the start of the case. The rectocele was visualized bulging up under the posterior vaginal wall. The vaginal mucosa was grasped with Allis forcep and incised in the midline. A vascular plane was developed between the rectocele tissue and the vaginal wall. This plane was developed out to the sides where the lateral pelvic fascia and levator muscles were identified. The levator was somewhat diminutive in size. Superiorly the vaginal vault was foreshortened due to previous hysterectomy. Care was taken not to extend the incision up onto the apex of the vagina and cause any more shortening. Once the rectocele was completely dissected out and the lateral attachment points for the sutures were clearly visualized, the lateral pelvic fascia and levator muscles were approximated in the midline with interrupted figure of eight sutures. Once this was completed and maintained reduction of the rectocele, the excess vaginal wall in the posterior aspect was removed sharply and then closed in the midline with running 3-0 chromic. Digital rectal exam revealed no persistence of the rectocele and good construction of the rectovaginal septum...
any thoughts out there?
