I agree with 58661, but there is a code for both the remaining procedures. If you look at 58558 this will include the D & C and diagnostic hysteroscopy. See what you think.Can someone help me out with this op note. I just want to make sure that I am in the right ballpark. I have a little doubt...
Procedure: Lap left salpingo-oophorectomy, diagnostic hysteroscopy, D&C
Pro Op Dx: Left ovarian mass, endometrial mass
Post Op Dx: Left ovarian mass, endometrial mass except no endometrial mass seen
Trocar was placed in the perioneal cavity without difficulty. CO2 gas was insufflated with initial filling pressure of 4.......Laparoscope with camera was inserted in to the trochar sleeve. The cyst and its benign appearance was appreciable. .....Using a grasper through the lower trocar and the gyrus cutting forceps, I was able to easily come across the infundibular pelvic ligament and uteroovarian ligament. The speciman was then placed in an endobag and it was brought to the abdominal wall with the tube and the ovary in it with removal of the trocar. The proximal part of the bag was opened outside the abdomen with upward pressure bringing the cystic ovary firmly to the abdominal wall. I was able to drain some fatty debris consistent with a dermoid.......the ovary was decompressed enough to come through the trocar site......therefore, with the procedure complete, attention was then turned to the hysteroscopy, a D&C, removal of mass. Speculum was placed in the posterior vagina and tail of the cervix was grasped with a single tooth tenaculum. using the hysteroscope and normal saline as a distention median, the uterine cavity was thoroughly visualized with negative findings. Hysteroscope was removed. The uterine cavity was sounded to 3 3/4 inches. Thorough curetting through 360 degrees was performed with scant tissue obtained. No cervical dilatation was required. Hysteroscope was readvanced and again normal endometrial cavity confirmed, therefore procedure complete.
I chose the following: I wasn't sure about the last one or if the second one might be inclusive. Any input?
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