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Vaginal Removal of Fibroid-Help w/ cpt codes

  1. #1
    Default Vaginal Removal of Fibroid-Help w/ cpt codes
    Medical Coding Books
    Please help. I'm thinking this is an unlisted procedure code 58999. I don't think it's 58145 Myomectomy vaginal approach. Any advice greatly appreciated.

    The report reads:

    POSTOPERATIVE DIAGNOSIS: Symptomatic cervical pedunculated fibroid.

    PROCEDURE PERFORMED: Vaginal removal of fibroid.



    URINE OUTPUT: 100 cc.

    FLUIDS: 400 cc of crystalloid.

    FINDINGS: A 4 cm pedunculated cervical fibroid, dilated cervix.

    INDICATIONS FOR PROCEDURE: The patient is a 42-year-old with symptomatic cervical fibroid. She has had heavy periods and passage of clot between periods for several months. She had been seen 2 to 3 months ago and counseled on need for surgical management. She was asked to follow up until recently where again she returned with heavy bleeding, and preop labs showing anemia, was counseled on need for removal, and has elected to proceed. She was counseled extensively on risks, benefits, alternatives to procedure, including risk of definitive surgery if bleeding was not able to be contained at the time of surgery.

    OPERATIVE COURSE: The patient was taken to the operating room where general anesthesia was found to be adequate. She was prepped and draped in normal sterile fashion. The bladder was cleared of 100 cc of urine and legs were placed in Allen stirrups. A weighted speculum was then inserted vaginally and using a Jacobs retractor, the fibroid was grasped with tension. The pedicle was able to be identified and delivered through the cervix. A Heaney clamp was then placed around the pedicle. A single suture of 0 Vicryl was then placed around the pedicle. Bleeding was hemostatic. A final inspection demonstrated no additional bleeding, and the pedicle was sore within the cervical canal. All instrumentation was then removed from the vaginal canal. All sponge, lap, needle counts were correct x2 and the patient was transferred to recovery room in stable condition.

  2. Default
    "CervicalFfibroid": intra mural( with the tissue), or on the surface either as submucous or as polypoidal/pedunculated, or sometimes it may be out of the cervical lateral wall into the broard ligament when it is known as broard ligament fibroid. The broard ligament fibroid, intramural are very cumbersome procedures and are real major procedures.
    This polypoidal cervical fibroid in the endocervical canal pedunculated(4cms diameter?!), dilating the cervix also a cumbersome procedure and needs a great skill and risk to do vaginally; the pedunculation is the 'advantage'.
    The appearance and the physician's diagnosis is (clinically) Myoma-the size contour and the cut section all would have favored for fibroid. It was not just a polyp to say it was polypectomy removal . (There is no polypectomy removal code by the way)
    It was a pedunculated 4cms cervival Surface Myoma (at the canal side) Removal Vaginal approach . The code assignment is in favor of 58145

    "The removal of uterine Myoma(Cervix is the lower part of the uterus) excision/removal from the surface; vaginal approach "- ECTOMY VAGINAL APPROACH- 58415 makes good validation, no matter how the technique was.

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