debellis59
Networker
I'm kind of at a loss on how to code this. Hymenectomy doesn't seem quite right, although that's the code the midwife selected. This is about 5 weeks post-delivery. I'm leaning toward 57135, but would like someone's feedback on this. Any help is appreciated.
Verbal consent obtained
Written consent not obtained
Consent given by: Patient
Patient identity confirmed per policy: Yes
Procedural pause: Immediately prior to the procedure a pause per universal protocol was called .
Location performed: Other Other location: Clinic
Preparation
Protective barrier: Mask, Hand scrub and Gloves
Indications for procedure: Hymenal remnant
Supporting diagnosis: S/P 2* perineal laceration repair
Procedure preparation:
Local anesthesia used?: Yes
Anesthesia: Local infiltration
Local anesthetic: Lidocaine 1% without epinephrine
Anesthetic total (ml): 3.5
Patient sedated: No
Post-procedure:
Patient tolerance: Patient tolerated the procedure well with no immediate complications
After pt emptied her bladder she was positioned in normal support. 3.5 mL 1% lidocaine injected in the surrounding tissue @ 1 mL bleeding noted at that time. Dr. F called in to assess the lesion and she agreed with plan to clamp and excise the protruding lesion. When anesthesia was verified a clamp was placed where the hymenal tissue met the vaginal wall. The tissue was removed against the clamp with a scalpel. After 2 minutes the clamp was removed and per Dr. F's recommendation silver nitrate sticks were used to achieve hemostasis. Total EBL 3 mL. Pt tolerated procedure well. After care instructions reviewed.
Verbal consent obtained
Written consent not obtained
Consent given by: Patient
Patient identity confirmed per policy: Yes
Procedural pause: Immediately prior to the procedure a pause per universal protocol was called .
Location performed: Other Other location: Clinic
Preparation
Protective barrier: Mask, Hand scrub and Gloves
Indications for procedure: Hymenal remnant
Supporting diagnosis: S/P 2* perineal laceration repair
Procedure preparation:
Local anesthesia used?: Yes
Anesthesia: Local infiltration
Local anesthetic: Lidocaine 1% without epinephrine
Anesthetic total (ml): 3.5
Patient sedated: No
Post-procedure:
Patient tolerance: Patient tolerated the procedure well with no immediate complications
After pt emptied her bladder she was positioned in normal support. 3.5 mL 1% lidocaine injected in the surrounding tissue @ 1 mL bleeding noted at that time. Dr. F called in to assess the lesion and she agreed with plan to clamp and excise the protruding lesion. When anesthesia was verified a clamp was placed where the hymenal tissue met the vaginal wall. The tissue was removed against the clamp with a scalpel. After 2 minutes the clamp was removed and per Dr. F's recommendation silver nitrate sticks were used to achieve hemostasis. Total EBL 3 mL. Pt tolerated procedure well. After care instructions reviewed.
