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AAPC OBGYN code a round, round 1 note 5

  1. Default AAPC OBGYN code a round, round 1 note 5
    Medical Coding Books
    I have spent hours on this note, and I need serious help. I believe I have tried every code in the book, and it still says "missing one or more codes". Can someone please help me?

    The codes that have been accepted are: 58750 and 58925 with diagnoses 256.4, 620.2, 614.6 and 625.9

    Here is the op note:

    PREOPERATIVE DIAGNOSIS:
    Chronic pelvic pain.
    Pelvic adhesions.
    Ovarian cyst.

    POSTOPERATIVE DIAGNOSIS:
    Chronic pelvic pain.
    Pelvic adhesions.
    Ovarian cyst.
    Polycystic ovaries.

    PROCEDURE TITLE;
    Attempted diagnostic laparoscopy.
    Exploratory laparotomy.
    Pelvic adhesiolysis.
    Removal of two para-ovarian cysts, one on the right and one on the left.
    Bilateral tuboplasty.
    Left ovarian wedge resection
    Right ovarian drilling.
    Chromotubation.
    Abdominal lavage.

    PROCEDURE: Under general anesthesia in the dorsal lithotomy position after routine prep of the vagina and the anterior abdominal wall, the patient was draped in the usual manner of surgery.

    A weighted speculum was placed into the vagina. The anterior lip of the
    cervix was grasped. The HUMI manipulator was inserted and inflated.
    A small incision was made in the umbilicus and the Veress needle was
    inserted into the abdomen. It was very difficult to have a clear view
    after the Veress needle was in. After several attempts with no success, this part of the procedure was canceled.

    The abdomen was entered through a Ffannenstiel incision. The incision was
    extended downward through fat and fascia. The rectus muscle was separated
    and then the peritoneum was incised perpendicular to the skin incision.
    The uterus was moved forward. Both round ligaments were grasped and brought into the field. All the pelvic adhesions were removed connecting the ovary and tubes. Also two paraatubal cysts, one on the right and on the left, were removed and sent for pathological study. Chromotubation was performed. No patency was obtained. The fibrotic area of the left tube was removed. The tube on the left was approximated together in layers and 6-0 and 7-0 pos was utilized. The mucosa was put together first with several 6-0 pos. Then the serosa was imbricated with interruped sutures using also 6-0 and 7-0 pos.
    Patency was obtained after chromotubation with indigo carmine. The identical operation was performed on the right. After completion of both the right and left side, chromotubation was performed again and patency was obtained.

    Since we had been using a special solution from the beginning of the surgery, some of this solution was utiiized to clear the tube uterine pathway with an excess of indigo carmine. This solution consisted of a combination of Macxojdex, Dextrose, Ringer's Lactate, Decadron, Phenergan and claforan. This solution was utilized thoughout the surgery in order to keep the pelvis moist. Some microsurgical instruments were utilized to perform the surgery for this patient.

    The sponge count and instrument count were okay by the nurse in charge. The abdomen was closed in layers. The peritoneum was closed with running 2-0 vicryl suture. The fat and fascia were closed with running 2-0 Vicryl suture beginning at each end of the abdominal incision, The skin edges were approximated with subcuticular suture using 2-0 Vicryl before the abdomen was completely closed. The fascia and the skin edges were infittrated with 0.5% Marcaine. A sterile dressing was placed over the wound. The patient tolerated the procedure well. The patient was instructed to go home today or in the morning on a regular diet. She will use Orudis 25 mg q,6h. p.r.n. Restrictions included no heavy lifting for a few days. She was instructed to return to my office in a week for followup. Apparently the patient is doing okay and her condition now is okay. She should be discharged with no problem.
    Last edited by cyndiann; 12-30-2011 at 06:50 PM.

  2. #2
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by cyndiann View Post
    I have spent hours on this note, and I need serious help. I believe I have tried every code in the book, and it still says "missing one or more codes". Can someone please help me?

    The codes that have been accepted are: 58750 and 58925 with diagnoses 256.4, 620.2, 614.6 and 625.9

    Here is the op note:

    PREOPERATIVE DIAGNOSIS:
    Chronic pelvic pain.
    Pelvic adhesions.
    Ovarian cyst.

    POSTOPERATIVE DIAGNOSIS:
    Chronic pelvic pain.
    Pelvic adhesions.
    Ovarian cyst.
    Polycystic ovaries.

    PROCEDURE TITLE;
    Attempted diagnostic laparoscopy.
    Exploratory laparotomy.
    Pelvic adhesiolysis.
    Removal of two para-ovarian cysts, one on the right and one on the left.
    Bilateral tuboplasty.
    Left ovarian wedge resection
    Right ovarian drilling.
    Chromotubation.
    Abdominal lavage.

    PROCEDURE: Under general anesthesia in the dorsal lithotomy position after routine prep of the vagina and the anterior abdominal wall, the patient was draped in the usual manner of surgery.

    A weighted speculum was placed into the vagina. The anterior lip of the
    cervix was grasped. The HUMI manipulator was inserted and inflated.
    A small incision was made in the umbilicus and the Veress needle was
    inserted into the abdomen. It was very difficult to have a clear view
    after the Veress needle was in. After several attempts with no success, this part of the procedure was canceled.

    The abdomen was entered through a Ffannenstiel incision. The incision was
    extended downward through fat and fascia. The rectus muscle was separated
    and then the peritoneum was incised perpendicular to the skin incision.
    The uterus was moved forward. Both round ligaments were grasped and brought into the field. All the pelvic adhesions were removed connecting the ovary and tubes. Also two paraatubal cysts, one on the right and on the left, were removed and sent for pathological study. Chromotubation was performed. No patency was obtained. The fibrotic area of the left tube was removed. The tube on the left was approximated together in layers and 6-0 and 7-0 pos was utilized. The mucosa was put together first with several 6-0 pos. Then the serosa was imbricated with interruped sutures using also 6-0 and 7-0 pos.
    Patency was obtained after chromotubation with indigo carmine. The identical operation was performed on the right. After completion of both the right and left side, chromotubation was performed again and patency was obtained.

    Since we had been using a special solution from the beginning of the surgery, some of this solution was utiiized to clear the tube uterine pathway with an excess of indigo carmine. This solution consisted of a combination of Macxojdex, Dextrose, Ringer's Lactate, Decadron, Phenergan and claforan. This solution was utilized thoughout the surgery in order to keep the pelvis moist. Some microsurgical instruments were utilized to perform the surgery for this patient.

    The sponge count and instrument count were okay by the nurse in charge. The abdomen was closed in layers. The peritoneum was closed with running 2-0 vicryl suture. The fat and fascia were closed with running 2-0 Vicryl suture beginning at each end of the abdominal incision, The skin edges were approximated with subcuticular suture using 2-0 Vicryl before the abdomen was completely closed. The fascia and the skin edges were infittrated with 0.5% Marcaine. A sterile dressing was placed over the wound. The patient tolerated the procedure well. The patient was instructed to go home today or in the morning on a regular diet. She will use Orudis 25 mg q,6h. p.r.n. Restrictions included no heavy lifting for a few days. She was instructed to return to my office in a week for followup. Apparently the patient is doing okay and her condition now is okay. She should be discharged with no problem.
    A couple suggestions to go back and look at, the tuboplasty is a unilateral code, but was done bilaterally so you probably need a 50 modifier on that. And look at 58350 for the Chromotubation. Also dx code you should have V64.41 to indicate the change from a laparoscopic procedure to a laparotomy.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. Default
    Arlene,
    I want to thank you so much for your help. That one V code was what I was missing. Makes me feel dumb.

  4. #4
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by cyndiann View Post
    Arlene,
    I want to thank you so much for your help. That one V code was what I was missing. Makes me feel dumb.
    Well don't feel dumb! Just means you learned one thing you will never forget! Glad I was able to provide some assistance...
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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