Jenetteis
Networker
I am trying to code for s/p revision of vaginal septum resection secondary to postoperative hemorrhage but I am at a loss. Has anyone else coded for this before? Thanks in advance 
Operation - Exam under anesthesia, Repair Vaginal Tear, revison of vaginal septum resection ,control of post op hemorrhage
The patient was taken to the OR where general endotracheal anesthesia was induced. The patient was placed in the dorsal lithotomy position with her legs supported using candy cane stirrups. The patient was then prepped and draped in the normal sterile fashion. A time-out was performed to confirm correct patient, correct procedure. A deaver retractor was used to visualized the vagina. A large clot was evacuated. The vagina was then copiously irrigated with sterile water. The vagina was then inspected and a largely intact incision was noted longitudinally, both inferior and superior. Two cervices were noted and appeared normal. An small area of separation was noted, with a small amount of active bleeding. The posterior portion of the incision was oversewn from the apex to the introitus using 3-0 vicryl in a running/locked fashion. One small area about 1 cm above the introitus in this incision line continued a bleed. A figure of 8 was placed using the same suture. Excellent hemostasis was noted. The vagina was then packed the Kerlix with premarin cream. A foley catheter was placed without difficulty. All sponge, lap, and needle counts were correct x 2 at the end of the procedure. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
Operation - Exam under anesthesia, Repair Vaginal Tear, revison of vaginal septum resection ,control of post op hemorrhage
The patient was taken to the OR where general endotracheal anesthesia was induced. The patient was placed in the dorsal lithotomy position with her legs supported using candy cane stirrups. The patient was then prepped and draped in the normal sterile fashion. A time-out was performed to confirm correct patient, correct procedure. A deaver retractor was used to visualized the vagina. A large clot was evacuated. The vagina was then copiously irrigated with sterile water. The vagina was then inspected and a largely intact incision was noted longitudinally, both inferior and superior. Two cervices were noted and appeared normal. An small area of separation was noted, with a small amount of active bleeding. The posterior portion of the incision was oversewn from the apex to the introitus using 3-0 vicryl in a running/locked fashion. One small area about 1 cm above the introitus in this incision line continued a bleed. A figure of 8 was placed using the same suture. Excellent hemostasis was noted. The vagina was then packed the Kerlix with premarin cream. A foley catheter was placed without difficulty. All sponge, lap, and needle counts were correct x 2 at the end of the procedure. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.