The patient was originally seen 3 days earlier for a vaginal vault suspension intra-peritoneal approach. During the post op appointment the patient complained of right leg numbness and pain. She was taken back to the OR on 08/21/2019 for a release of nerve entrapment, and an extra-peritoneal vault suspension. CPT 64722 (Decompression; unspecified nerve(s) (specify).) seems to be the best code that I was able to locate for the release. There is not a revision of a vaginal vault suspension should I code it as;
64722-78, and 57282-78,52?
POST-OP DIAGNOSIS: Post-operative pain [G89.18]Nerve entrapment [G58.9]
PROCEDURE(S): Procedure(s):
RELEASE OF NERVE ENTRAPMENT, extraperitoneal vault suspension
COMPLICATIONS: none
FINDINGS: release of right sided suspension sutures and LOA, placement of new suspension on the contralateral side
DISPOSITION: awakened from anesthesia, extubated and taken to the recovery room in a stable condition, having suffered no apparent untoward event.
CONDITION: doing well without problems
TECHNIQUE:
This patient was evaluated and consented for surgical correction of right sided nerve entrapment and pain and all questions were answered in the preoperative area.
The patient was taken to the OR. She was placed in the
dorsal lithotomy position. She was prepped and draped in normal sterile
fashion under general endotracheal anesthesia. Time-out was performed per
universal protocol and Foley catheter was placed.
Prior anterior wall suture line was reopened with suture scissors and bluntly. The cuff and suspension sutures suspected of nerve entrapment were identified. The paravaginal space was developed on the right side until the ischial spine was clearly palpable. The coccygeus muscle was tracked towards the sacrum in ensure proper stitch placement.
The Capio needle device was placed on the sacrospinous ligament 2cm medial to the spine on the SSL complex on the left side gently sweeping aside the sigmoid for access and deployed with prolene 2-0 to avoid all neurovascular structures. This was repeated on the same side.
The sutures were brought through the apical aspect of the vaginal cuff.
The anterior wall incision was then reapproximated and suspension sutures tied down.
All instrument, sponge and needle counts were correct x2
64722-78, and 57282-78,52?
POST-OP DIAGNOSIS: Post-operative pain [G89.18]Nerve entrapment [G58.9]
PROCEDURE(S): Procedure(s):
RELEASE OF NERVE ENTRAPMENT, extraperitoneal vault suspension
COMPLICATIONS: none
FINDINGS: release of right sided suspension sutures and LOA, placement of new suspension on the contralateral side
DISPOSITION: awakened from anesthesia, extubated and taken to the recovery room in a stable condition, having suffered no apparent untoward event.
CONDITION: doing well without problems
TECHNIQUE:
This patient was evaluated and consented for surgical correction of right sided nerve entrapment and pain and all questions were answered in the preoperative area.
The patient was taken to the OR. She was placed in the
dorsal lithotomy position. She was prepped and draped in normal sterile
fashion under general endotracheal anesthesia. Time-out was performed per
universal protocol and Foley catheter was placed.
Prior anterior wall suture line was reopened with suture scissors and bluntly. The cuff and suspension sutures suspected of nerve entrapment were identified. The paravaginal space was developed on the right side until the ischial spine was clearly palpable. The coccygeus muscle was tracked towards the sacrum in ensure proper stitch placement.
The Capio needle device was placed on the sacrospinous ligament 2cm medial to the spine on the SSL complex on the left side gently sweeping aside the sigmoid for access and deployed with prolene 2-0 to avoid all neurovascular structures. This was repeated on the same side.
The sutures were brought through the apical aspect of the vaginal cuff.
The anterior wall incision was then reapproximated and suspension sutures tied down.
All instrument, sponge and needle counts were correct x2