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hysterectomy w/?

  1. Default hysterectomy w/?
    Medical Coding Books
    needing help with a report from an OB doc that is reporting questionably???

    how would this be coded?

    admit diagnosis:
    uterine prolapse
    nodules, possibly due to fibroids

    postop diagnosis:
    uterine prolapse
    small right ovarian cycst, 3x4cm which ruptured and left ovarian cyst which also ruptured

    the patient is a 43 yr old female admitted for total vaginal hysterectomy with possible bilateral salpingo-oophorectomy and with anterior and posterior repair with possible TVH. The patient was admitted and taken to operative suite and did the vaginal hysterectomy with right salpingo-oophorectomy. However, she kept bleeding and the bleeding was high enough I could not ridge, so I had to convert it to a total abdominal hysterectomy. Even though therte was no uterus left and only I had to close the vaginal cuff and also to take care of the bleeding. However, the patient had exploratory laparotomy done and bleeding stopped and vaginal cuff closed with no problem and the patient tolerated the prodcedure well ...............(addtl post op basic info/instructions)

    which codes would this type of documentation justify charging for? I'm new to OB and would really appreciate some direction.

    Thanks in advance )

  2. #2
    From what I understand you would code to the highest possible procedure, tahyster w/ salpingo-oopherectomy, the exploretory lap is overridden, I believe, by the abdominal hyster b/c you opened her up, correct? I assume abdominal means an abdominal incision across the pubic area? Code to the highest surgical procedure but do not overcode. You will see it in the CPT coding manual. But, since you never left the operating room and it all happened at the same time it would seem it is a total abdominal hysterectomy with a salpingo-oophorectomy, even though you initially went thru the vagina. But, please seek counsel on this. Good luck...........sure do miss OB/GYN!!
    Cathleen A. Manna, CPC-A

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