rockylopez
Networker
Hello. I am really in the need of advice. Upon reviewing the op note i came with cpt code 58120 but i am very confused with the intratuerine tamponade balloon as the second procedure and need anyone's experience if the cpt code 58120 is included with the balloon procedure. I am used to coding for endometrial ablations with hysteroscopies but this is a suction d and c.
any input is appreciated.
Pre-procedure diagnosis:
1. Abnormal uterine bleeding
2. Uterine polyps
Post-procedure diagnosis:
1. Abnormal uterine bleeding
2. Endometrial polyps
Procedures performed:
1. Suction, dilation and curettage
2. Placement of intrauterine tamponade balloon
Technique/Procedure:
transvaginal
Complications: uterine atony with need for utrauterine tamponade balloon placement
The patient was taken to the operating room where general endotrachel anesthesia was found to be adequate. She was prepped and draped in the normal sterile fashion in the dorsal lithotomy position in the Allen stirrups. A weighted speculum was placed and the anterior lip of the cervix was grasped with the single-tooth tenaculum. A 10 mm curved curette was used. The suction was tested to 65 mmHg. Alternating passes of the suction and sharp currete were performed until a gritty texture was noted circumferentially. Continued bleeding was noted which was coming from the uterus. A Foley catheter was placed in the uterus and the balloon was inflated with 15 cc of fluid. Cervical abrasions were note with oozing which was not responsive to direct pressure. This bleeding was addressed with silver nitrate. The patient tolerated the procedure. Sponge, lap and needle counts were correct x3. The patiet was taken to the operating room in stable condition. The intrauterine foley balloon will be removed in 3 hours.
any input is appreciated.
Pre-procedure diagnosis:
1. Abnormal uterine bleeding
2. Uterine polyps
Post-procedure diagnosis:
1. Abnormal uterine bleeding
2. Endometrial polyps
Procedures performed:
1. Suction, dilation and curettage
2. Placement of intrauterine tamponade balloon
Technique/Procedure:
transvaginal
Complications: uterine atony with need for utrauterine tamponade balloon placement
The patient was taken to the operating room where general endotrachel anesthesia was found to be adequate. She was prepped and draped in the normal sterile fashion in the dorsal lithotomy position in the Allen stirrups. A weighted speculum was placed and the anterior lip of the cervix was grasped with the single-tooth tenaculum. A 10 mm curved curette was used. The suction was tested to 65 mmHg. Alternating passes of the suction and sharp currete were performed until a gritty texture was noted circumferentially. Continued bleeding was noted which was coming from the uterus. A Foley catheter was placed in the uterus and the balloon was inflated with 15 cc of fluid. Cervical abrasions were note with oozing which was not responsive to direct pressure. This bleeding was addressed with silver nitrate. The patient tolerated the procedure. Sponge, lap and needle counts were correct x3. The patiet was taken to the operating room in stable condition. The intrauterine foley balloon will be removed in 3 hours.