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any suggestions

  1. #1
    Default any suggestions
    Medical Coding Books
    Suspected uterine anomaly.

    POSTOPERATIVE DIAGNOSIS: Confirmed uterine anomaly with duplication of the cervix the lower uterine tract.

    PROCEDURE: 1. Hysteroscopy.

    2. Laparoscopy.

    3. Dilatation of both uterine horns.

    ANESTHESIA: Local.

    FINDINGS: A normal appearing single uterus. Normal appearing tubes and ovaries are identified. No evidence of endometriosis, uterine polyp or peritoneal scarring is noted. The patient demonstrates a division of the vagina into two separate halves with a transverse division and two clear, separate cervixes. Hard copy photographs of the patient's findings are obtained.

    INDICATIONS: This a nulligravida patient who presents with a history of a diagnosis from a previous doctor that she has two separate uteruses. Bimanual evaluation by me in the office demonstrated only a single uterus. The patient is not aware of any variations in her normal routine female hygiene. And her husband is also unaware of any complications. The patient had been evaluated an HSG which did demonstrate only a unilateral spill and suspicion of a possible duplication of the uterine tract. Of interest, the patient's mother demonstrates a past history of DES exposure for her and this would then potentially be a second generation effect from DES.

    DESCRIPTION OF PROCEDURE: 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 vaginal and abdominal surgery. During the prep, the patient's relaxation os showed a clear delineation of a duplication of the vagina with a transverse orientation of the division between the two separate halves with a smaller division on the anterior leaf and a much larger division on the posterior leaf, with a clear, complete layer of vaginal skin between the two halves. Both halves are noted to have their own cervix and both cervixes are cannulized to identify both tubal openings. Unilateral single openings are noted in both sides and a suspicion for complete duplication is evaluated with laparoscopy.

    Attention is turned to the abdomen, where a small infraumbilical incision is made in the skin with the knife and the Veress needle is inserted to allow for insufflation of approximately 3 liters of CO2 gas. The 10-mm trocar is inserted and a laparoscopic camera identifies a normal appearing uterus and normal appearing tubes and ovaries. And the uterine manipulator moves the entire uterus and is single in nature without incident. There is fairly strong evidence laparoscopically of a thick midline septum or fusion of two upper poles, two otherwise unicornuate uteruses, but without our previous hysteroscopic identification of the two cervixes. The suspicion for any significant abnormality through laparoscopy would be only casual. Hard copy photographs of the patient's pelvic anatomy are obtained and the pneumoperitoneum is reduced and the trocar is removed. Our uterine manipulator is removed and no evidence of vaginal bleeding is appreciated. The abdominal wound is closed with three interrupted sutures of 3-0 Vicryl in a vertical mattress fashion. The patient tolerated the procedure well and went to the recovery room in good condition.

  2. #2
    Albany, New York
    The only procedure that I'm getting from the documentation you provide is 49320.

    The report does indicate any placement of a hysteroscope.
    Karen Maloney, CPC
    Data Quality Specialist

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