LTibbetts
Guest
I am coding a mini laparotomy with left salpingo-oophorectomy for the first time and could use some help. They are also inserting an IUD. Here is some of the op note:
"mini laparotomy with left salpingo-oophorectomy - a 1-cm verticle incision was made approximately 4 cm inferior to the umbilicus overlying the cyst. I attempted to place the 10-12 laparoscopic trocar through this incision directly into the cyst but was uncomfortable proceeding blindly. I went ahead with a 5-cm suprapubic Pfannenstiel skin incision which was carried down to the fascia. Fascia was opened transversely and then blunty and sharply dissected off underlying rectus muscles. Rectus muscles were divided in midline. Peritoneum was entered sharply. Peritoneal incision was extended bluntly. Then using a hand in the abdominal cavity underneath the high incision on the abdomen, the 10-12 trocar was popped throught he fascia and peritoneum and then guided over the cystic mass and into the mass. Pool suction was then used to evacuate the contents of the largest cavity. with this I was able to bring one of the smaller cyst cavities to the suprapubic incision. I was able to, under direct visualization, pop the 10-12 trocar into that cavity and evacuate the cavity's fluid. The thrid cystic cavity was evacuated in th same manner. This allowed the entire adnexa, including the cystic mass, to be brought up through the incision. With the adnexa externalized, I was able to isolate the infundibulopelvic ligament and palpate the ureter well inferior to the ligament where the vessels were."
I am completely lost with this one. Any advice?
Any help would be great. Also, there was an IUD insertion done as well. Do I need a modifier for that at all?
"mini laparotomy with left salpingo-oophorectomy - a 1-cm verticle incision was made approximately 4 cm inferior to the umbilicus overlying the cyst. I attempted to place the 10-12 laparoscopic trocar through this incision directly into the cyst but was uncomfortable proceeding blindly. I went ahead with a 5-cm suprapubic Pfannenstiel skin incision which was carried down to the fascia. Fascia was opened transversely and then blunty and sharply dissected off underlying rectus muscles. Rectus muscles were divided in midline. Peritoneum was entered sharply. Peritoneal incision was extended bluntly. Then using a hand in the abdominal cavity underneath the high incision on the abdomen, the 10-12 trocar was popped throught he fascia and peritoneum and then guided over the cystic mass and into the mass. Pool suction was then used to evacuate the contents of the largest cavity. with this I was able to bring one of the smaller cyst cavities to the suprapubic incision. I was able to, under direct visualization, pop the 10-12 trocar into that cavity and evacuate the cavity's fluid. The thrid cystic cavity was evacuated in th same manner. This allowed the entire adnexa, including the cystic mass, to be brought up through the incision. With the adnexa externalized, I was able to isolate the infundibulopelvic ligament and palpate the ureter well inferior to the ligament where the vessels were."
I am completely lost with this one. Any advice?
Any help would be great. Also, there was an IUD insertion done as well. Do I need a modifier for that at all?
