Jenetteis
Networker
Patient initially scheduled for a Hysteroscopic Endometrial Ablation (58563) and Laparoscopic Tubal Ligation (58661) but surgeon aborted the laparoscopic procedure due to "abundant adhesions". My plan is to bill 49320-52 and 58563, 59 but wanted a second opinion. Any advice is greatly appreciated. Thank you!
Description
The patient was taken to the OR and placed under general anesthesia without difficulty. The patient was placed in the dorsal lithotomy position. The patient was prepped and draped in the usual sterile fashion. An exam performed under anesthesia confirmed a 10 cm size anteverted uterus. Given her hx of c sections, the cervix was adhered to anterior abdominal wall. A sterile bi-valved speculum was placed in the vagina and the anterior lip of the cervix was grasped with a single tooth tenaculum. The cervix was then gently dilated with hanks dilators to accommodate the hysteroscope. The uterine cavity was then sounded to 10 cm, and entered under direct visualization with the hysteroscope. Both ostia visualized. Hysteroscope was removed. Using the NovaSure device an ablation was performed without difficulty. Length 6cm width 4.7cm. Total ablative time was 37 seconds. Device was removed without difficulty. Hysteroscope was then reintroduced and cavity was visualized. There was minimal bleeding noted from the cervical os. Hulka was placed on cervix and attention was turned to the abdominal portion of the procedure. Multiple attempts were made to enter abdominal cavity through the umbilicus but I visualized abundant adhesions. Given her body habitus and possible risks the laparoscopy portion was aborted and the procedure was concluded. All instruments were removed from the abdomen and vagina and excellent hemostasis was noted. The patient tolerated the procedure well. Sponge, lap and needle counts were correct x2. The patient was taken to the recovery room in stable condition.
Description
The patient was taken to the OR and placed under general anesthesia without difficulty. The patient was placed in the dorsal lithotomy position. The patient was prepped and draped in the usual sterile fashion. An exam performed under anesthesia confirmed a 10 cm size anteverted uterus. Given her hx of c sections, the cervix was adhered to anterior abdominal wall. A sterile bi-valved speculum was placed in the vagina and the anterior lip of the cervix was grasped with a single tooth tenaculum. The cervix was then gently dilated with hanks dilators to accommodate the hysteroscope. The uterine cavity was then sounded to 10 cm, and entered under direct visualization with the hysteroscope. Both ostia visualized. Hysteroscope was removed. Using the NovaSure device an ablation was performed without difficulty. Length 6cm width 4.7cm. Total ablative time was 37 seconds. Device was removed without difficulty. Hysteroscope was then reintroduced and cavity was visualized. There was minimal bleeding noted from the cervical os. Hulka was placed on cervix and attention was turned to the abdominal portion of the procedure. Multiple attempts were made to enter abdominal cavity through the umbilicus but I visualized abundant adhesions. Given her body habitus and possible risks the laparoscopy portion was aborted and the procedure was concluded. All instruments were removed from the abdomen and vagina and excellent hemostasis was noted. The patient tolerated the procedure well. Sponge, lap and needle counts were correct x2. The patient was taken to the recovery room in stable condition.