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gyn surgical op note-HELP

  1. #1
    Default gyn surgical op note-HELP
    Medical Coding Books
    The op note has diagnostic laparoscopy and diagnostic hysteroscopy with D & C. We have coded 625.0 and 625.9 and 58558. op note is looking for one or more additional cpt codes. We have looked at 12 additional codes (anesthesia, surgical, and one HCPCS)and we are not finding anything that is correct. Any ideas on what the missing code/codes are?

  2. #2
    Smile GYN Surgical op note

    without knowing all of the history or seeing the op note- my guess is that the other CPT is 49320- based on the ICD-9 you are assiging

    625.0, 625.9 perhaps the H & P can guide you as to why the Doctor is doing both and this will help you in your definite choice.

    Glad to help

  3. Default
    Hysteroscopy does not bring forth all the diagnostic values of pelvic diseases.Hysteroscopy is useful only to diagnose conditions pertaining to Vagina, cervix and the uterine cavity, mucosa and any mass or fibroid in the uterus.

    for any diseases pertaining to inside/with the pelvic cavity, Uterine adenexa, pelvic peritoneum, fallopian tubes, ovaries and the surrounding structures in the pelvis is diagnosed by Laparoscopy only and not by Hysteroscopy.

    Another point is, the documented diagnosis code 625.0 Dyspareunia denotes many conditions of which the most important are Pelvic Endometriosis deposits (in the uterine adenexa, Pelvic peritoneum, uterine serosa and rectal serosa ,rectal seedlings etc) AND pelvic Inflammatory Diseases- PID like T.O.MASS, hydrosalphynx, abscess OR masses in the ovary, adenxa and peritoneum.
    what I am trying to bring forth is these causes of dyspareunia could be diagnosed only with Diagnostic Laparoscopy / diagnostic Peritoneoscopy.

    So, apart from the CPT 58558, it is mandatory to report the code 49320, though it is a separate procedure. This procedure is separate, distinct the site of entry and the organs examined are distinctly different from the Hysteroscopic procedure.

    So, Marsico9 is absolutely correct with 49320 along with 58558, for the diagnosis 625.0, unless you come out with more history,diagnoses, and Op notes.

  4. #4
    Default op notes
    Thank you both!! There doesnt seem to be enough info on this op note to determine what they are looking for?
    Appreciate it!!

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