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Thread: Help code

  1. #1
    Join Date
    Apr 2007
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    Bangor, Maine
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    719

    Default Help code

    Promo: Code Books
    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?

    58661
    58555-59
    57505-59

  2. #2
    Join Date
    Apr 2007
    Location
    Kokomo, IN
    Posts
    769

    Default help code

    Quote Originally Posted by LTibbetts View Post
    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?

    58661
    58555-59
    57505-59
    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.

  3. #3
    Join Date
    Apr 2007
    Location
    Bangor, Maine
    Posts
    719

    Default

    Anna, thank you so much! That looks like the perfect code. I guess I should have done a little more research in my CPT book. Do I still need a -59 modifier for that code?

    We have a new surgeon on board and i have a feeling she is going to be throwing a lot more surgeries at us, which is great, but I am pretty new to this arena of coding. Thank you so much for your help

  4. #4
    Join Date
    Apr 2007
    Location
    Bangor, Maine
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    Default

    Oops, never mind. I just looked it up in the CCI edits myself....

  5. #5
    Join Date
    Apr 2007
    Location
    Kokomo, IN
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    769

    Default help code

    Quote Originally Posted by LTibbetts View Post
    Anna, thank you so much! That looks like the perfect code. I guess I should have done a little more research in my CPT book. Do I still need a -59 modifier for that code?

    We have a new surgeon on board and i have a feeling she is going to be throwing a lot more surgeries at us, which is great, but I am pretty new to this arena of coding. Thank you so much for your help
    No problem. That's what this is for. To be used as a sounding board. Good luck!

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