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Help w/CPT Code(s)

  1. Question Help w/CPT Code(s)
    Medical Coding Books
    My doctor performed the following surgery and I need your help coding it.

    Preoperative Diagnosis:
    1. Twelve Week Size Uterine Fibroids
    2. Abnormal Vagnial Bleeding.

    Postoperative Diagnosis:
    1. Twelve Week Size Uterine Fibriods.
    2. Abnormal Vaginal Bleeding.
    3. Pelvic Adhesions.
    4. Left Ovarian Cyst.
    5. Left Paratubal Cyst of Morgagni.
    6. Left Hydrosalpinx.

    Procedure Performed:
    1. Evaluation and Exam under anesthesia.
    2. Hysteroscopy
    3. Pfannenstiel Laparotomy.
    4. Adhesiolysis.
    5. Myomectomies.
    6. Uterine Surgical Reconstruction.
    7. Left Ovarian Cystectomy.
    8. Resection of left Paratubal Cyst of Morgagni.

    The hysterscopy procedure began by placing a single tooth tenaculum on the anterior lip of the cervix and by introducing a hysteroscope through the cervix into the uterine cavity. The hysteroscope had a 30 degree optical angle and its flow channel was attached to a 3 CCD digital video camera. Normal saline hydrodistention took place to expand the uterine cavity revealing a normal smooth endometrium and no evidence of submucosal pathology. At this point, the hysteroscopy procedure was discontinued. (58555 - Diagnostic Hysterscopy)

    At this point, a Pfannenstiel laparotomy incision was sharply made and carried down to the fascia using monopolar electrosurgery. The fascia was then incised transversely and extended laterally in each direction with monopolar electrosurgery. The rectus muscles were then sepparated in the midline and incision in the linea alba was made with monopolar electrosurgery and extended superiorly and inferiorly. The rectus muscles were separated. The peritoneum as grasped with kelly clamps and entered with monopolar electrosurgery.

    Ther peritoneal incision was extended superiorly and inferiorly using monopolar electrosurgery. The bowel was then packed out of the pelvis using moist laparotomy sponges and then an O'Connor-O'Sullivan retractor was placed in the abdominal cavity and expanded.

    Pelvic Findings:
    1. The anterior vesicouterine cul-de-sac was obliterated by multiple thick vascular adhesions extending from 2 anterior subserosal fibroids to the vesicouterine cul-de-sac.
    2. The bladder was otherwise found to be normal with no evidence of pathology.
    3. Both round ligaments were covered by thick vascular adhesions extending from the fibroids to the vesicouterine reflection.
    4. There was no evidence of an inguinal hernia.
    5. The internal openings were found to be normal with no evidence of pathology.
    6. The right fallopian tube was occluded in the isthmic ampullary portion and scarred, usual previous tubal sterilization procedure.
    7. The left fallopian tube was proximally occluded and had left a large hydrosalpinx and left distal tubal occlusion. Left hydrosalpinx was adherent to the pelvic sidewall.
    8. There was a large left paratubal cyst Morgagni, also adherent to the left pelvic sidewall by adhesions.
    9. There was a large left ovarian cyst. That was adherent to the left pelvic sidewall and the posterior aspect of the uterus.
    10. The uterus was enlarged, approximately 12 weeks in size with a large subserosal fibroid located under the right broad ligament and extended toward the right pelvic floor.
    11. The posterior cul-de-sac of Douglas was completely obliterated by adhesions. The left ovarian cyst and adhesions extending to the bowel, omentum, and the posterior aspect of the uterus.
    12. Both uterosacral ligaments were adherent to both adnexa.
    13. Both pelvic sidewalls contained adhesions extending from both adnexa to both pelvic sidewalls.

    At this point, adhesiolysis began. This was done with DeBakeys and monopolar electrosurgery. The left ovary and left paratubal cyst of Morgagni could be mobilized away from the adhesions and the bowel and omentum. Furthermore adhesiolysis allowed for mobilization of the uterus away from the bowel, omentum, and signoid colon.

    At this point, Pitressin at a dilution of 20 international units in 30 mL of Ringer's was injected under the peritoneum overlying the fibroids to minimize the blood loss during the upcoming myomectomy procedures.

    Monopolar electrosurgery was used to make an incision on the peritoneum over the fibroids, the fibroids were shelled out with traction and countertraction provided by DeBakeys and the suction tip. Monopolar electrosurgery was used to shell out the fibroids. The fibroid located on right broad liagment was carefully shelled out oand hemostasis was secured with monopolar electrosurgery and multiple 3-1 Vicryl pop offs. Then, the uterus was reconstructed by putting multiple 3-- Vicryl pop-offs, to approximate the myometrium and then a 3-0 Vicryl was used to approximate the peritoneum. (CPT 58140)

    At this time, the left paratubal cyst of Morgagni was grasped with DeBakeys and removed with monopolar electrosurgery and submitted to pathology for histologic diagnosis. (CPT ????)

    Subsequently, the left ovarian cyst was mobilized. An incision was made on the left ovarian capsule and the cyst was resected with DeBakeys and Kitner tip. The capsule of the left ovarian cyst was submitted to pathology for histologic diagnosis. (CPT ????)

    At this point, the pelvis was copiously irrigated with Ringer's. The Ringer's were aspirated through a suction tip. Interceed was applied over the uterus for adhesion prophylaxis. A thick Gelfoam was also applied over the Interceed to secure hemostasis. All laparotomy sponges were removed. The peritoneum was approximated with 2-0 Vicryl running stitch. The fascia was irrigated and hemostasis was secured with monopolar electrosurgery. The fascia was approximated by using #0 PDS loop beginning in the left angle and ending on the right angle. Subcutaneous tissue was irrigated with Ringer's and 4-0 Dexon subcuticular stitch was used to approximate the skin edges. All sponge, needle, and instrument counts were correct twice at the end of the procedure. The patient was awakened, extubated, and transferred to postanesthesia care unit in stable condition with normal vital signs. The estmated blood loss was minimal.


  2. #2
    Idaho Falls, Idaho
    58662 would encompass both
    Tesja Erickson, CPC, CPMA COBGC, CEMC
    The Coding Surgeon
    Medical Documentation & Coding Consultant
    2012 AAPC Idaho Falls Chapter President
    2011 AAPC Idaho Falls Chapter President-Elect

  3. Default
    58662 is laparoscopic ... since he performed the removal of the paratubal and the ovarian cystectomy during an open procedure, do you know what code I would use?

    Thanks for your assistance!!

  4. #4
    Default Cyst removal
    I would use the code 58925 for the cyst removal.

    Sue,-CPC, COBGC

  5. Smile
    Thanks for your assistance coding this procedure.

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