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GYN surgical procedure help!!

  1. #1
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default GYN surgical procedure help!!
    Medical Coding Books
    I'm doing something "new" (again) and I do love learning new things! BUT, I've been stuck on this one all morning. I think I might be making it more difficult than it really needs to be. I found my procedures (or so I thought) but I end up with CCEdits stating flat out "no, can't be coded together". So, I'll remove the one that's being bundled but then it looks like I'm missing something.
    I'm not certain what to look for exactly, I'm not sure if I'm reading the report correctly, missing something. Frankly, I'm lost! Please help, and an explanation as to how you come to your conclusion would REALLY be helpful and appreciated! If you know of any websites or books that might help teach me, please let me know!! I'm going to be doing more and more of these procedures as this Dr. has just started here.
    Thanks in advance - I know this is time consuming and really appreciate the input! I'm looking for procedure code help only. (no need to bother with the dx codes)

    Here is the whole report (less patient and provider info)

    PREOPERATIVE DIAGNOSIS: Abnormal uterine bleeding, dysmenorrhea, pelvic pain.

    POSTOPERATIVE DIAGNOSIS: Mild endometriosis, normal hysteroscopy.

    PROCEDURE: D&C, hysteroscopy, laparoscopy, fulguration of endometriosis.

    SURGEON:
    ASSISTANT:

    ANESTHESIA: General

    COMPLICATIONS: None

    ESTIMATED BLOOD LOSS: Less than 15 cc

    OPERATIVE FINDINGS: On hysteroscopy, the endometrial cavity had a normal contour with no evidence of endometrial polyps or fibroids. Benign appearing, somewhat thickened endometrium. On laparoscopy, there were numerous adhesions in the upper abdomen and right upper quadrant from prior surgery. In the pelvis, there were endometriotic implants involving the posterior cul-de-sac, right uterosacral ligament, and right ovarian fossa, which were fulgurated. Status post tubal ligation. Otherwise, normal appearing uterus and adnexa.

    OPERATIVE DICTATION: The patient was brought to the operating room and uneventfully placed under general anesthesia. She was prepped and draped in the dorsal lithotomy position and her bladder drained. A weighted speculum was placed. The cervix was visualized and grasped with a fine toothed tenaculum. The cervix was gently dilated with Hager dilators. Hysteroscopy was performed using a 25 degree rigid hysteroscope and normal saline as distention media. Visualization was excellent. Findings were as described above. The hysteroscope was removed. Gentle, but thorough, sharp curettage was then performed in all four quadrants. Endometrial curettings were sent to pathology for review. A uterine manipulating device was placed. We then changed clothes and proceeded to the abdominal portion of the case. A 5 mm infraumbilical skin incision was made and carried to the abdominal fascia. A Veress needle was introduced without difficulty. A water drop test was performed. The abdomen was insufflated with several liters of carbon dioxide. A 5 mm trocar and the laparoscope were introduced. Visualization was excellent. The findings were as described above. A 5 mm suprapubic port was then placed under direct visualization. A J hook with monopolar cautery was used to fulgurate the endometriotic lesions. The pelvis was then irrigated and checked for hemostasis. Then we proceeded to closure. The trocars were removed and excess carbon dioxide expressed from the abdomen. The subcutaneous spaces were irrigated and checked for hemostasis. The skin incisions were closed with surgical glue. The uterine manipulated device was removed. There were no complications, and the patient was transferred to the recovery room in excellent and stable condition.


    so - I feel I'm WAY OFF base....
    FIRST -I came up with 57558 / 58558 /49320 /58353 (had edits)
    THEN - I change it to 58120 / 58558 / 49320 / 58353 (edits)
    THEN - 58120 / 49320 / 58353 (no edits) I just know I'm not correct, something doesn't seem right but that's what I'm sitting on for now...

    HELP!
    Donna, CPC, CPC-H

  2. #2
    Default procedure
    Quote Originally Posted by dmaec View Post
    I'm doing something "new" (again) and I do love learning new things! BUT, I've been stuck on this one all morning. I think I might be making it more difficult than it really needs to be. I found my procedures (or so I thought) but I end up with CCEdits stating flat out "no, can't be coded together". So, I'll remove the one that's being bundled but then it looks like I'm missing something.
    I'm not certain what to look for exactly, I'm not sure if I'm reading the report correctly, missing something. Frankly, I'm lost! Please help, and an explanation as to how you come to your conclusion would REALLY be helpful and appreciated! If you know of any websites or books that might help teach me, please let me know!! I'm going to be doing more and more of these procedures as this Dr. has just started here.
    Thanks in advance - I know this is time consuming and really appreciate the input! I'm looking for procedure code help only. (no need to bother with the dx codes)

    Here is the whole report (less patient and provider info)

    PREOPERATIVE DIAGNOSIS: Abnormal uterine bleeding, dysmenorrhea, pelvic pain.

    POSTOPERATIVE DIAGNOSIS: Mild endometriosis, normal hysteroscopy.

    PROCEDURE: D&C, hysteroscopy, laparoscopy, fulguration of endometriosis.

    SURGEON:
    ASSISTANT:

    ANESTHESIA: General

    COMPLICATIONS: None

    ESTIMATED BLOOD LOSS: Less than 15 cc

    OPERATIVE FINDINGS: On hysteroscopy, the endometrial cavity had a normal contour with no evidence of endometrial polyps or fibroids. Benign appearing, somewhat thickened endometrium. On laparoscopy, there were numerous adhesions in the upper abdomen and right upper quadrant from prior surgery. In the pelvis, there were endometriotic implants involving the posterior cul-de-sac, right uterosacral ligament, and right ovarian fossa, which were fulgurated. Status post tubal ligation. Otherwise, normal appearing uterus and adnexa.

    OPERATIVE DICTATION: The patient was brought to the operating room and uneventfully placed under general anesthesia. She was prepped and draped in the dorsal lithotomy position and her bladder drained. A weighted speculum was placed. The cervix was visualized and grasped with a fine toothed tenaculum. The cervix was gently dilated with Hager dilators. Hysteroscopy was performed using a 25 degree rigid hysteroscope and normal saline as distention media. Visualization was excellent. Findings were as described above. The hysteroscope was removed. Gentle, but thorough, sharp curettage was then performed in all four quadrants. Endometrial curettings were sent to pathology for review. A uterine manipulating device was placed. We then changed clothes and proceeded to the abdominal portion of the case. A 5 mm infraumbilical skin incision was made and carried to the abdominal fascia. A Veress needle was introduced without difficulty. A water drop test was performed. The abdomen was insufflated with several liters of carbon dioxide. A 5 mm trocar and the laparoscope were introduced. Visualization was excellent. The findings were as described above. A 5 mm suprapubic port was then placed under direct visualization. A J hook with monopolar cautery was used to fulgurate the endometriotic lesions. The pelvis was then irrigated and checked for hemostasis. Then we proceeded to closure. The trocars were removed and excess carbon dioxide expressed from the abdomen. The subcutaneous spaces were irrigated and checked for hemostasis. The skin incisions were closed with surgical glue. The uterine manipulated device was removed. There were no complications, and the patient was transferred to the recovery room in excellent and stable condition.


    so - I feel I'm WAY OFF base....
    FIRST -I came up with 57558 / 58558 /49320 /58353 (had edits)
    THEN - I change it to 58120 / 58558 / 49320 / 58353 (edits)
    THEN - 58120 / 49320 / 58353 (no edits) I just know I'm not correct, something doesn't seem right but that's what I'm sitting on for now...

    HELP!
    Here's what I get:
    58558 hysteroscopy D&C, the report indicates a hysteroscope was used, but does not indicate endometrial ablation, just currettage.
    58662 lap with fulguration of lesions (endometrectomy) by any method

    See if this works for you.

  3. #3
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    Thanks Anna!
    Yes, I REALLY wanted to use my 58558! LOL but the CCIedits kept taking it away due to my other codes. which, it appears, are WAY off!!.
    I kept getting an Edit for the lap (diagnostic) too (49320), I didn't like it or want it, but the Edits kept pointing me to it..

    I like the 58662 - apparently I was in the wrong area on that too!

    (sheesh, I'd better learn this quick)

    thanks tons for your input!
    Donna, CPC, CPC-H

  4. #4
    Default help
    No problem! Anytime!

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