The provider dropped code 58571. I believe the correct code would be the 58552 per the documentation. Which code would be correct?
Procedure Details:
The patient was seen in the preoperative area. The risks, benefits, complications, treatment options, non-operative alternatives, expected recovery and outcomes were discussed with the patient. The possibilities of reaction to medication, pulmonary aspiration, injury to surrounding structures, bleeding, recurrent infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The site of surgery was properly noted/marked if necessary. The patient was actively warmed in the preoperative area. Preoperative antibiotics have been ordered and given within 1 hours of incision. Venous thrombosis prophylaxis have been ordered including bilateral sequential compression devices.
Patient was taken to the operating room, placed in supine position, given satisfactory general endotracheal anesthesia. Legs were placed in Allen stirrups. Abdomen, perineum and vagina were prepped and draped in sterile fashion. Foley catheter was inserted. A large uterine V-Care manipulator was applied. 0.5% Marcaine was used to anesthetize all trocar sites. An 8 mm incision was made above the umbilicus. A Veress needle was inserted without difficulty. CO2 was used to inflate the abdomen. Operative ports were placed 9 cm laterally and slightly caudal. She was put in Trendelenburg position. Bowel was swept out of the pelvis. Robot was docked with monopolar scissors in the right hand and a Vessel sealer in the left.
The fallopian tubes were grasped at their distal end and elevated. The Vessel sealer was used to divide the mesosalpinx separating the tube from its underlying ovary. The utero-ovarian ligaments were isolated bilaterally, bipolar cauterized and divided. The round ligaments were bipolar cauterized and divided, and the anterior cul-de-sac was developed on the right partially, taking bladder off the lower uterine segment. There was significant scarring noted, and great care was used to dissect off the bladder flap. The posterior leaf of the broad ligament was divided bilaterally. Uterine vessels were skeletonized, then Vessel sealer used to cauterize and divide bilaterally. Proximal and distal cardinal ligaments were bipolar cauterized and divided. A posterior colpotomy was created on the V-ring. It was carried 360 degrees circumferentially, releasing cervix from vagina. Uterus, cervix and bilateral fallopian tubes were removed through the vagina.
Specimens were sent to Pathology for gross inspection and permanent.
The vaginal cuff was then closed with running 0-SutureEase suture from one vaginal apex to the opposite apex, looping suture back several passes to complete the locking stitch. The pelvis was thoroughly irrigated. Hemostasis was excellent. Teesel was applied to the vaginal cuff and pedicles
Cystoscopy was then performed. Bladder appeared intact with no trauma, bubble noted in dome of bladder. Bilateral ureteral efflux noted.
At this time, CO2 was allowed to escape from the abdomen. Trocars and instruments were removed. All ports sites were closed with subcuticular 4-0 Monocryl.Dermabond was applied.
She tolerated the procedure without difficulty, was extubated and taken to recovery in stable condition.
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Cancer Staging: no
Follow Up:no
Procedure Details:
The patient was seen in the preoperative area. The risks, benefits, complications, treatment options, non-operative alternatives, expected recovery and outcomes were discussed with the patient. The possibilities of reaction to medication, pulmonary aspiration, injury to surrounding structures, bleeding, recurrent infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The site of surgery was properly noted/marked if necessary. The patient was actively warmed in the preoperative area. Preoperative antibiotics have been ordered and given within 1 hours of incision. Venous thrombosis prophylaxis have been ordered including bilateral sequential compression devices.
Patient was taken to the operating room, placed in supine position, given satisfactory general endotracheal anesthesia. Legs were placed in Allen stirrups. Abdomen, perineum and vagina were prepped and draped in sterile fashion. Foley catheter was inserted. A large uterine V-Care manipulator was applied. 0.5% Marcaine was used to anesthetize all trocar sites. An 8 mm incision was made above the umbilicus. A Veress needle was inserted without difficulty. CO2 was used to inflate the abdomen. Operative ports were placed 9 cm laterally and slightly caudal. She was put in Trendelenburg position. Bowel was swept out of the pelvis. Robot was docked with monopolar scissors in the right hand and a Vessel sealer in the left.
The fallopian tubes were grasped at their distal end and elevated. The Vessel sealer was used to divide the mesosalpinx separating the tube from its underlying ovary. The utero-ovarian ligaments were isolated bilaterally, bipolar cauterized and divided. The round ligaments were bipolar cauterized and divided, and the anterior cul-de-sac was developed on the right partially, taking bladder off the lower uterine segment. There was significant scarring noted, and great care was used to dissect off the bladder flap. The posterior leaf of the broad ligament was divided bilaterally. Uterine vessels were skeletonized, then Vessel sealer used to cauterize and divide bilaterally. Proximal and distal cardinal ligaments were bipolar cauterized and divided. A posterior colpotomy was created on the V-ring. It was carried 360 degrees circumferentially, releasing cervix from vagina. Uterus, cervix and bilateral fallopian tubes were removed through the vagina.
Specimens were sent to Pathology for gross inspection and permanent.
The vaginal cuff was then closed with running 0-SutureEase suture from one vaginal apex to the opposite apex, looping suture back several passes to complete the locking stitch. The pelvis was thoroughly irrigated. Hemostasis was excellent. Teesel was applied to the vaginal cuff and pedicles
Cystoscopy was then performed. Bladder appeared intact with no trauma, bubble noted in dome of bladder. Bilateral ureteral efflux noted.
At this time, CO2 was allowed to escape from the abdomen. Trocars and instruments were removed. All ports sites were closed with subcuticular 4-0 Monocryl.Dermabond was applied.
She tolerated the procedure without difficulty, was extubated and taken to recovery in stable condition.
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Cancer Staging: no
Follow Up:no
