RachelH30
New
Hi All,
I am having a terrible time deciphering what my urologist is doing when he performs procedures for a female prolapse.
He is stating that he is performing a partial vaginectomy because he is removing full thickness vaginal skin, approximately 75%, but, he is not doing this for malignancy or dysplasia. He is performing this for a prolapse. I am having a hard time deciding if this is truly just a colpoclesis he is performing, or if I should be coding for a partial vaginectomy AND colpoclesis as well. To me, this note reads as a colpopclesis for prolapse, along with a posterior colporrhaphy repair and perineorrhaphy. I am torn if he truly did the work of a partial vaginectomy or not- What should I be coding.... 57106, or 57120; or BOTH?
PREOPERATIVE DIAGNOSIS: Uterine prolapse with vaginal vault prolapse, rectocele and perineocele.
POSTOPERATIVE DIAGNOSIS: Uterine prolapse with vaginal vault prolapse, rectocele and perineocele.
PROCEDURE: Partial vaginectomy with colpocleisis, posterior colporrhaphy and perineorrhaphy with rigid cystoscopy.
ANESTHESIA: Spinal. BLOOD LOSS: 5 mL.
FINDINGS: near total uterine prolapse. Uneventful removal of approx. 75% of full-thickness vaginal skin to achieve reduction of the prolapse and posterior plication.
INDICATIONS: This is a 74-year-old woman with bothersome vaginal bulge, uterovaginal prolapse managed with a pessary. She is having worsening leakage and recurrent bladder infections, pessary has also become dislodged on several occasions. She wished to proceed with surgical repair and coordination with a hysterectomy with another provider. She has been medically optimized though she is a high risk patient with poorly controlled diabetes and chronic steroid use.
DESCRIPTION PROCEDURE: The patient was brought to the operating room. Spinal anesthesia was induced. She was prepped and draped in the lithotomy position and Dr. Schoel performed a vaginal hysterectomy and closed the vaginal cuff. Foley catheter was then placed and the case was turned over to me. I placed a self-retaining vaginal Lone Star retractor. Examination showed asymmetric prolapse with a short anterior vaginal wall component with a posterior enterocele, rectocele and perineocele.
We began by grasping the anterior vaginal wall just to the level of the vaginal cuff and dissecting off full thickness vaginal skin from the pubocervical fascia to the level of the bladder neck. We were able to palpate the Foley balloon, indicating we had not dissected up past the bladder neck. We then marked out a posterior V incision for the perineorrhaphy and levatorplasty, made a incision in the perineum and using sharp dissection, carried this proximally up to the vaginal apex of the enterocele. Lateral full-thickness skin flaps were also dissected up to the lateral endopelvic fascia, which would allow for plication and narrowing of the vaginal canal. The skin was excised and removed. We then used a 2-0 V-Loc suture to do a running anterior, posterior incision. Three rows of sutures were then placed to fully reduce the prolapse past the level of the bladder neck.
We removed the Foley catheter, performed cystoscopy showed normal bladder without evidence of foreign bodies, tumors or stones. There was no evidence for cystitis. Each ureteral orifice was orthotopic and was effluxing Pyridium-stained urine. The scope was removed. The Foley catheter was replaced. We then focused our attention on the posterior colporrhaphy and perineorrhaphy. Using interrupted 2-0 Vicryl sutures. We did a posterior plication to narrow the vaginal introitus to 1:1.5 fingerbreadths. We trimmed excess full-thickness vaginal mucosa and then closed the remaining posterior vaginal skin in a T-shaped incision to the vaginal introitus. Using 0 Vicryl sutures, we performed the distal plication and perineorrhaphy further narrowing the introitus to 1.5 fingerbreadths. The vaginal skin was then closed all the way to the introitus and the perineal skin was closed with running 4-0 Monocryl suture. We removed approximately 75% of the vagina in full - thickness dissection to expose the underlying fascia. The perineal area was instilled with bupivacaine solution for postoperative pain control. The Foley was left to closed bag drainage. She was taken to the recovery room in stable condition. She will be admitted for observation.
I am having a terrible time deciphering what my urologist is doing when he performs procedures for a female prolapse.
He is stating that he is performing a partial vaginectomy because he is removing full thickness vaginal skin, approximately 75%, but, he is not doing this for malignancy or dysplasia. He is performing this for a prolapse. I am having a hard time deciding if this is truly just a colpoclesis he is performing, or if I should be coding for a partial vaginectomy AND colpoclesis as well. To me, this note reads as a colpopclesis for prolapse, along with a posterior colporrhaphy repair and perineorrhaphy. I am torn if he truly did the work of a partial vaginectomy or not- What should I be coding.... 57106, or 57120; or BOTH?
PREOPERATIVE DIAGNOSIS: Uterine prolapse with vaginal vault prolapse, rectocele and perineocele.
POSTOPERATIVE DIAGNOSIS: Uterine prolapse with vaginal vault prolapse, rectocele and perineocele.
PROCEDURE: Partial vaginectomy with colpocleisis, posterior colporrhaphy and perineorrhaphy with rigid cystoscopy.
ANESTHESIA: Spinal. BLOOD LOSS: 5 mL.
FINDINGS: near total uterine prolapse. Uneventful removal of approx. 75% of full-thickness vaginal skin to achieve reduction of the prolapse and posterior plication.
INDICATIONS: This is a 74-year-old woman with bothersome vaginal bulge, uterovaginal prolapse managed with a pessary. She is having worsening leakage and recurrent bladder infections, pessary has also become dislodged on several occasions. She wished to proceed with surgical repair and coordination with a hysterectomy with another provider. She has been medically optimized though she is a high risk patient with poorly controlled diabetes and chronic steroid use.
DESCRIPTION PROCEDURE: The patient was brought to the operating room. Spinal anesthesia was induced. She was prepped and draped in the lithotomy position and Dr. Schoel performed a vaginal hysterectomy and closed the vaginal cuff. Foley catheter was then placed and the case was turned over to me. I placed a self-retaining vaginal Lone Star retractor. Examination showed asymmetric prolapse with a short anterior vaginal wall component with a posterior enterocele, rectocele and perineocele.
We began by grasping the anterior vaginal wall just to the level of the vaginal cuff and dissecting off full thickness vaginal skin from the pubocervical fascia to the level of the bladder neck. We were able to palpate the Foley balloon, indicating we had not dissected up past the bladder neck. We then marked out a posterior V incision for the perineorrhaphy and levatorplasty, made a incision in the perineum and using sharp dissection, carried this proximally up to the vaginal apex of the enterocele. Lateral full-thickness skin flaps were also dissected up to the lateral endopelvic fascia, which would allow for plication and narrowing of the vaginal canal. The skin was excised and removed. We then used a 2-0 V-Loc suture to do a running anterior, posterior incision. Three rows of sutures were then placed to fully reduce the prolapse past the level of the bladder neck.
We removed the Foley catheter, performed cystoscopy showed normal bladder without evidence of foreign bodies, tumors or stones. There was no evidence for cystitis. Each ureteral orifice was orthotopic and was effluxing Pyridium-stained urine. The scope was removed. The Foley catheter was replaced. We then focused our attention on the posterior colporrhaphy and perineorrhaphy. Using interrupted 2-0 Vicryl sutures. We did a posterior plication to narrow the vaginal introitus to 1:1.5 fingerbreadths. We trimmed excess full-thickness vaginal mucosa and then closed the remaining posterior vaginal skin in a T-shaped incision to the vaginal introitus. Using 0 Vicryl sutures, we performed the distal plication and perineorrhaphy further narrowing the introitus to 1.5 fingerbreadths. The vaginal skin was then closed all the way to the introitus and the perineal skin was closed with running 4-0 Monocryl suture. We removed approximately 75% of the vagina in full - thickness dissection to expose the underlying fascia. The perineal area was instilled with bupivacaine solution for postoperative pain control. The Foley was left to closed bag drainage. She was taken to the recovery room in stable condition. She will be admitted for observation.