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any suggestions

  1. #1
    Default any suggestions
    Medical Coding Books
    need your help with this. what would you code?

    The patient was brought to the operating room and placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion for a laparoscopic procedure. Under adequate general anesthesia, vaginal retractors were placed, and the anterior lip of the cervix grasped with an Allis clamp. An acorn uterine manipulator was then inserted, and the vaginal retractors removed. The bladder was straight catheterized, and attention was drawn to the patient's abdomen. Here a small incision was made in the skin with a knife and a large Veress needle was inserted into the abdomen. Then, 2.4 liters of CO2 gas was instilled, and the Veress needle removed. An operative trocar and sleeve was then inserted, and the trocar was removed. The operative scope was placed, and the above noted findings appreciated. The intestines and uterus were manipulated for examination. Since I did not find anything significantly wrong with this patient, and I did want to try to help her with her dyspareunia, I went ahead and identified the ureters bilaterally and then went ahead and burned the uterosacral ligaments bilaterally with the bipolar cautery. Photographs were taken throughout the procedure and at the end of the procedure. The procedure was then terminated. The instrumentation was removed. The CO2 gas was exhausted, and the incision closed with a deep and subcuticular stitch of 4-0 Monocryl. Sponge, needle, and instrument counts were correct at the end of the procedure. The patient tolerated the procedure well and went to the recovery room in good condition.

  2. #2
    Albany, New York
    I've spent a good amount of time reviewing this, and the only thing that I come up with is an Unlisted Laparoscopy code--58578
    Karen Maloney, CPC
    Data Quality Specialist

  3. #3
    thats what i thought as well. thats what i coded. how long have you been coding obgyn. the reason why i posted this was because the office coded somthing different and my claim is being denied bc of the office. i like to see other inputs on this as well.

  4. #4
    I agree with the unlisted

  5. #5
    I also agree with 58578 unlisted laparoscopy procedure uterus

    Julie, CPC

  6. #6
    thanks for all of your imputs.

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