Hi OBGYN Group,
This patient had a Diagnostic laparoscopy, Hysteroscopy with Symphion and resection of adenomyosis, SSLF with Enplace, Anterior and Posterior colporrhaphy, urethral bulking with bulkamid and cystoscopy, removal of labial lesion. I am inquiring if I could bill the 49320 with the 58563 or is the 49320 considered a "look see" and bundled into the 58563 as the Hysterscope was used. I will condense the op note as much as possible for review of pertinent information. I am also sending a query on the Wedge Resection technique to remove the labial lesion, would that technique be considered as the 114XX codes even though no documentation of size is listed? Thank you for taking the time to review my codes, much appreciated.
Operative Note:
A Veress needle was utilized to get into the peritoneal axis. Once we were intraperitoneal with low opening presure of 5 mm Hg, we allowed CO2 gas to insufflate her abdomen until we reached a pressure of 15 mmHg. Once we reached that pressure, a 5-mm optical trocar was inserted under direct visualization at this site. One additional trocar was placed on the left lower quadrants approximately 2 fingerbreadths above the anterior superior iliac spine and 2 cm medial to that spot under direct visualization. The inferior epigastric vessels were visualized prior to trocar insertion in trying to avoid injury to this vessel.
First, a survey of the cavity was performed. The pelvis was inspected with the above noted. The camera port was also removed once CO2 gas was evacuated from the abdomen and after several Valsalva breaths were given. The skin incisions were closed with interrupted 4-0 Moncryl suture and surgical glue.
The cervix was grasped with a single tooth tenaculum. The cervix was sequentially dilated and sounded at 7cm. The symphion hysteroscope was inserted into the uterine cavity. Tubal ostia were noted bilaterally with a thick midline septum and a bicornuate uterine cavity. The Sypmhion resection device was used to resect thickened tissue and focal pockets of adenomyosis. The bipolar aspect of the resection device was passed along the decidual layer until hemostasis was noted. The scope was removed. Fluid deficits were within normal limits.
Next the SSLF was began. Procedure completed in it's entirety.
Two Allis clamps were applied horizontally along the vaginal incision to grasp the dependent portion of the cystocele for traction. The epithelium was further separated from the vaginal muscularis sharply with tenotomy and metzenbaum scissors and bluntly with peanut sponges and a raytec. Excess vaginal mucosal skin was trimmed. The vaginal wall was then plicated in a vertical imbricating fashion using 2-0 PDS. We then began closure of the anterior vaginal epithelial incision with a 2-0 Vicryl sutures in a running locked stitch from lateral to medial with two separate sutures from each vaginal apex. The incision was intentionally left open after the first few throws from each side. The EnPlace prolene sutures were then tied down separately, one at a time until proper apical support was obtained and then they were tied together pushing the prolapse up to the anatomic position of the vaginal apex. The 2-0 PDS stitches were then tied down. We then finished closure of the anterior vaginal epithelial incision with the two 2-0 Vicryl sutures in a running locked stitch from lateral to medial.
Then performance of the single incision sling. The mid urethral zone was identified in reference to the Foley catheter and urethral meatus and local anesthetic solution was injected into the anterior vaginal wall at the mid urethral level for hydrodissection and vasoconstriction. Next, local was injected at the midline and to the left and right of midline directing the infiltration laterally towards the cephalad aspect of the inferior pubic ramus bilaterally. Care was taken to ensure that the sulcus was flattened and free of infiltration to minimize chance for buttonholing or tapping too close to the anterolateral sulcus. After completion of hydrodissection, 2 Allis clamps were used to grasp the anterior vaginal wall for traction. A 1.5 cm incision was made to the midline. Two Allis clamps were then placed on each cut edge of the incision for stabilization. Tenotomy scissors were used to create a small vaginal tunnel with sharp and blunt dissection above the anterior vaginal wall directed laterally towards the cephalad aspect of the inferior pubic ramus bilaterally. Dissection was carried out to the edge of the bone itself but no dissection into the obturator internus muscle. Once the dissection was complete, the sling was placed. The Altis system was used. An index finger was placed in the vagina for guidance. The Altis trocar was placed into the pre-dissected tract. The handle was held in horizontal slight upward canting to avoid buttonholing of the sulcus. Cephalad drift was used to allow passage around the inferior pubic ramus. A thumb was placed on the heel of the introducer to allow a push/pivot maneuver to place a fixed anchor into the obturator internus muscle membrane complex on the patient's left side. Proper handle deviation confirmed proper anchor placement, as well as a gentle tugging on the sling. Once the introducer was removed, it also confirmed proper anchor placement. The exact same sequence of steps was repeated on the patient's right side with adjustable anchor. Once it was complete, the introducer was removed and gentle tugging again confirmed proper anchor placement. The Foley catheter was then used to drain the bladder and then it was removed and a diagnostic cystoscopy was performed. Both ureters were effluxing normally and there were no lacerations or injury in the lower urinary tract. We used Crede maneuver to elicit loss of fluid from the urethral meatus and there was loss of fluid noted. The tensioning suture was used to adjust the tape until there was minimal to no leakage with Crede. After appropriate tensioning, the tensioning suture was cut and the vaginal incision was closed with 2-0 Vicryl suture in a running locked stitch. At this time, we placed the Foley back in the bladder.
Attention was then turned to the posterior compartment where 2 Allis clamps were placed in the posterior fourchette over the mucocutaneous border to reduce the markedly relaxed vaginal outlet. Dilute Marcaine solution was injected into the perineum. A diamond-shaped incision was made extending from the vaginal mucosa onto the perineum. The overlying skin was removed en bloc. We then began closure of the posterior colporrhaphy with a 2-0 Vicryl suture in a running locked stitch. We reapproximated the perineal body with a 0-Vicryl interrupted sutures x 2. We closed the remainder of the colporrhaphy to the level of the hymen. We closed the perineal skin with 2-0 Vicryl in a subcuticular fashion.
No bladder, ureteral, viscus, or solid organ injury were noted at the end of the procedure. Irrigation was performed. Vaginal packing was placed in the vagina. No complications. The sponge, needle and instrument count were correct x2. The patient tolerated the procedure well and went to the recovery room in stable condition and she is stable at the moment of this dictation.
Patient was positioned on the table in the lithotomy position, and was prepped and draped in a usual sterile fashion. Anaesthetic gel was administered inside the urethra, and the bladder was emptied using a disposable catheter.
At the start of the procedure, the water inflow was adjusted to produce an adequate stream. The Bulkamid Needle was then placed ¾ of the way into the needle channel of the rotatable sheath and the entire Bulkamid system was then advanced into the urethra until the bladder is visualised and inspected. The Bulkamid needle was then advanced into the needle channel on the rotatable sheath until the tip of the sheath is adjacent to the bladder neck.
The sheath was then rotated to the 7 o'clock position. The needed was then extend into the bladder until the 2cm mark on the needle is visible. The Bulkamid system was then retracted until the tip of the needle was resting on the bladder neck. The needle was then retracted into the sheath and approximately 1.5cm from the bladder neck the Bulkamid system was pressed parallel against the urethral wall and the needle is then advanced into the submucosal tissue ensuring that the bevel of the needle was facing towards the lumen. The needle was advanced approximately 0.5cm, and the Bulkamid hydrogel was then injected until the Bulkamid cushion was visible and reached the midline of the urethral lumen.
The needle was then retracted back into the rotatable sheath, and rotated to the next injection site. Subsequent injections were preformed at 5 o'clock, 2 o'clock and 10 o'clock all along the same plane as the original injection until all (4) cushions met at the midline of the urethral lumen. 1ml Total of Bulkamid Hydrogel was used.
Approximately 300cc of fluid was left in the bladder and upon completion.
Next a wedge resection technique was used to remove a midline labial lesion. The incision was closed with 4-0 Monocryl in a running non locked fashion, the area was hemostatic.
All instrument, sponge and sharps counts were correct x 2. The patient tolerated the procedure well and went to the recovery room in stable condition.
49320
58563
57282
57260
51715
11420
And I will be applying modifiers as well. Thanks again!
Dorine Marshall,CPC,COBGC
Tulsa,Ok
This patient had a Diagnostic laparoscopy, Hysteroscopy with Symphion and resection of adenomyosis, SSLF with Enplace, Anterior and Posterior colporrhaphy, urethral bulking with bulkamid and cystoscopy, removal of labial lesion. I am inquiring if I could bill the 49320 with the 58563 or is the 49320 considered a "look see" and bundled into the 58563 as the Hysterscope was used. I will condense the op note as much as possible for review of pertinent information. I am also sending a query on the Wedge Resection technique to remove the labial lesion, would that technique be considered as the 114XX codes even though no documentation of size is listed? Thank you for taking the time to review my codes, much appreciated.
Operative Note:
A Veress needle was utilized to get into the peritoneal axis. Once we were intraperitoneal with low opening presure of 5 mm Hg, we allowed CO2 gas to insufflate her abdomen until we reached a pressure of 15 mmHg. Once we reached that pressure, a 5-mm optical trocar was inserted under direct visualization at this site. One additional trocar was placed on the left lower quadrants approximately 2 fingerbreadths above the anterior superior iliac spine and 2 cm medial to that spot under direct visualization. The inferior epigastric vessels were visualized prior to trocar insertion in trying to avoid injury to this vessel.
First, a survey of the cavity was performed. The pelvis was inspected with the above noted. The camera port was also removed once CO2 gas was evacuated from the abdomen and after several Valsalva breaths were given. The skin incisions were closed with interrupted 4-0 Moncryl suture and surgical glue.
The cervix was grasped with a single tooth tenaculum. The cervix was sequentially dilated and sounded at 7cm. The symphion hysteroscope was inserted into the uterine cavity. Tubal ostia were noted bilaterally with a thick midline septum and a bicornuate uterine cavity. The Sypmhion resection device was used to resect thickened tissue and focal pockets of adenomyosis. The bipolar aspect of the resection device was passed along the decidual layer until hemostasis was noted. The scope was removed. Fluid deficits were within normal limits.
Next the SSLF was began. Procedure completed in it's entirety.
Two Allis clamps were applied horizontally along the vaginal incision to grasp the dependent portion of the cystocele for traction. The epithelium was further separated from the vaginal muscularis sharply with tenotomy and metzenbaum scissors and bluntly with peanut sponges and a raytec. Excess vaginal mucosal skin was trimmed. The vaginal wall was then plicated in a vertical imbricating fashion using 2-0 PDS. We then began closure of the anterior vaginal epithelial incision with a 2-0 Vicryl sutures in a running locked stitch from lateral to medial with two separate sutures from each vaginal apex. The incision was intentionally left open after the first few throws from each side. The EnPlace prolene sutures were then tied down separately, one at a time until proper apical support was obtained and then they were tied together pushing the prolapse up to the anatomic position of the vaginal apex. The 2-0 PDS stitches were then tied down. We then finished closure of the anterior vaginal epithelial incision with the two 2-0 Vicryl sutures in a running locked stitch from lateral to medial.
Then performance of the single incision sling. The mid urethral zone was identified in reference to the Foley catheter and urethral meatus and local anesthetic solution was injected into the anterior vaginal wall at the mid urethral level for hydrodissection and vasoconstriction. Next, local was injected at the midline and to the left and right of midline directing the infiltration laterally towards the cephalad aspect of the inferior pubic ramus bilaterally. Care was taken to ensure that the sulcus was flattened and free of infiltration to minimize chance for buttonholing or tapping too close to the anterolateral sulcus. After completion of hydrodissection, 2 Allis clamps were used to grasp the anterior vaginal wall for traction. A 1.5 cm incision was made to the midline. Two Allis clamps were then placed on each cut edge of the incision for stabilization. Tenotomy scissors were used to create a small vaginal tunnel with sharp and blunt dissection above the anterior vaginal wall directed laterally towards the cephalad aspect of the inferior pubic ramus bilaterally. Dissection was carried out to the edge of the bone itself but no dissection into the obturator internus muscle. Once the dissection was complete, the sling was placed. The Altis system was used. An index finger was placed in the vagina for guidance. The Altis trocar was placed into the pre-dissected tract. The handle was held in horizontal slight upward canting to avoid buttonholing of the sulcus. Cephalad drift was used to allow passage around the inferior pubic ramus. A thumb was placed on the heel of the introducer to allow a push/pivot maneuver to place a fixed anchor into the obturator internus muscle membrane complex on the patient's left side. Proper handle deviation confirmed proper anchor placement, as well as a gentle tugging on the sling. Once the introducer was removed, it also confirmed proper anchor placement. The exact same sequence of steps was repeated on the patient's right side with adjustable anchor. Once it was complete, the introducer was removed and gentle tugging again confirmed proper anchor placement. The Foley catheter was then used to drain the bladder and then it was removed and a diagnostic cystoscopy was performed. Both ureters were effluxing normally and there were no lacerations or injury in the lower urinary tract. We used Crede maneuver to elicit loss of fluid from the urethral meatus and there was loss of fluid noted. The tensioning suture was used to adjust the tape until there was minimal to no leakage with Crede. After appropriate tensioning, the tensioning suture was cut and the vaginal incision was closed with 2-0 Vicryl suture in a running locked stitch. At this time, we placed the Foley back in the bladder.
Attention was then turned to the posterior compartment where 2 Allis clamps were placed in the posterior fourchette over the mucocutaneous border to reduce the markedly relaxed vaginal outlet. Dilute Marcaine solution was injected into the perineum. A diamond-shaped incision was made extending from the vaginal mucosa onto the perineum. The overlying skin was removed en bloc. We then began closure of the posterior colporrhaphy with a 2-0 Vicryl suture in a running locked stitch. We reapproximated the perineal body with a 0-Vicryl interrupted sutures x 2. We closed the remainder of the colporrhaphy to the level of the hymen. We closed the perineal skin with 2-0 Vicryl in a subcuticular fashion.
No bladder, ureteral, viscus, or solid organ injury were noted at the end of the procedure. Irrigation was performed. Vaginal packing was placed in the vagina. No complications. The sponge, needle and instrument count were correct x2. The patient tolerated the procedure well and went to the recovery room in stable condition and she is stable at the moment of this dictation.
Patient was positioned on the table in the lithotomy position, and was prepped and draped in a usual sterile fashion. Anaesthetic gel was administered inside the urethra, and the bladder was emptied using a disposable catheter.
At the start of the procedure, the water inflow was adjusted to produce an adequate stream. The Bulkamid Needle was then placed ¾ of the way into the needle channel of the rotatable sheath and the entire Bulkamid system was then advanced into the urethra until the bladder is visualised and inspected. The Bulkamid needle was then advanced into the needle channel on the rotatable sheath until the tip of the sheath is adjacent to the bladder neck.
The sheath was then rotated to the 7 o'clock position. The needed was then extend into the bladder until the 2cm mark on the needle is visible. The Bulkamid system was then retracted until the tip of the needle was resting on the bladder neck. The needle was then retracted into the sheath and approximately 1.5cm from the bladder neck the Bulkamid system was pressed parallel against the urethral wall and the needle is then advanced into the submucosal tissue ensuring that the bevel of the needle was facing towards the lumen. The needle was advanced approximately 0.5cm, and the Bulkamid hydrogel was then injected until the Bulkamid cushion was visible and reached the midline of the urethral lumen.
The needle was then retracted back into the rotatable sheath, and rotated to the next injection site. Subsequent injections were preformed at 5 o'clock, 2 o'clock and 10 o'clock all along the same plane as the original injection until all (4) cushions met at the midline of the urethral lumen. 1ml Total of Bulkamid Hydrogel was used.
Approximately 300cc of fluid was left in the bladder and upon completion.
Next a wedge resection technique was used to remove a midline labial lesion. The incision was closed with 4-0 Monocryl in a running non locked fashion, the area was hemostatic.
All instrument, sponge and sharps counts were correct x 2. The patient tolerated the procedure well and went to the recovery room in stable condition.
49320
58563
57282
57260
51715
11420
And I will be applying modifiers as well. Thanks again!
Dorine Marshall,CPC,COBGC
Tulsa,Ok
