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Imbrication of anterior cystocele closure

  1. #1
    Question Imbrication of anterior cystocele closure
    Medical Coding Books
    Good evening,

    If I could please get assistance from an expert for help with this case. A patient had an anterior-posterior colporraphy who had a complicated course after the procedure. She had some vaginal bleeding which required a transfusion. She was re-examined under anesthesia and taken back to the operating room. There was bleeding and oozing from the anterior-posterior colporraphy. The doctor controlled the bleeding with imbricating stitches of the anterior vaginal vault. Should I assign 998.11 and 623.8 ICD9s with 45560 CPT? I appreciate your help. Thank you in advance!
    The patient is a normally healthy female who underwent an anterior-posterior colporrhapy. She initially had a complicated course after the procedure secondary to the vaginal packing falling out during the 1st day of the procedure. This was not recognized until postoperative day #1 at which time it was found that the packing had not been within the vagina for the first 24 hours. Examination at that time found her to have evidence of some vaginal bleeding but nothing significant at the time. She did require ultimately to be repacked again because of ongoing active vaginal bleeding and despite attempts to control this with conservative management she contined to have significant vaginal bleeding which required transfusion. Because of this somewhat complicated course the patient ultimately given recommendations for reexamination under anesthesia and closure of the incison.


    She was taken back to the operating room after packing the vagina had been unsuccessful and we found that the anterior opening of the vaginal colporrhaphy on the anterior wall of the vagina showed no active bleeding but there was a clot over the area which potentially was the source of the bleeding. Manipulation of the closure as well as the examination of the rectum and the posterior closure found no evidence of any active vaginal bleeding. I therefore allowed the anesthesiologist to awaken the patient with some Valsalva maneuvers and found that there was some bleeding and oozing from the anterior colporrhaphy. I lubricated over this area again and elected not to open up the anterior compartment again and therefore I did control bleeding with imbricating stiches of the anterior vaginal valut.
    Last edited by jsanc07; 02-10-2010 at 10:05 AM. Reason: Attached Op Report.

  2. #2
    Default
    pls include the op note (s)

    Quote Originally Posted by jsanc07 View Post
    Good evening,

    If I could please get assistance from an expert for help with this case. A patient had an anterior-posterior colporraphy who had a complicated course after the procedure. She had some vaginal bleeding which required a transfusion. She was re-examined under anesthesia and taken back to the operating room. There was bleeding and oozing from the anterior-posterior colporraphy. The doctor controlled the bleeding with imbricating stitches of the anterior vaginal vault. Should I assign 998.11 and 623.8 ICD9s with 45560 CPT? I appreciate your help. Thank you in advance!
    Rachele Porter, AS, CPC, CPC-H, CEDC
    no weapons formed against me shall prosper

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