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Posted By Maria on 03-21-2018, 16:07:14 in Ob-Gyn
Hi Melainie,

Am I any where in the ball park with my codes?

Thank you for all your help.

Procedure(s)
Laparoscopy with lysis of extensive adhesion (Add mod 22)
Bilateral salpingoophorectomy; (58661,50)
Anterior colporrhaphy with dissection and posterior colporrhaphy; (57260)
Revision of previous suburethral sling; ??
perineorrhaphy; Included
cystoscopy Included

Description of Findings: Examination under anesthesia revealed a absent cervix and uterus. No adnexal masses were appreciated. There was a 2nd degree midline cystocele and a 2nd degree midline rectocele. The perineal body was significantly shortened.

A 5 mm subumbilical incision was made. A 5 mm optical port was inserted. Proper insertion was confirmed with concurrent visualization via the laparoscope. An opening pressure of 2 mm Hg was noted.
 
The abdomen was insufflated with CO2. Under direct visualization, a 5 mm bladeless port was placed in the suprapubic region, 4 cm cephalad to the pubic symphysic. A probe was inserted and the bowel was mobilized out of the pelvis. Inspection of the pelvis and abdomen revealed absent uterus. There were extensive adhesions from the omentum to the anterior abdominal wall and to the adnexae. The left tube had a 3 cm simple paratubal cyst. Both ovaries and the right tube were normal. . The uterus was surgically absent.
 
A second 5 mm port was placed in the left upper quadrant, taking care to avoid the inferior midepigastric vessels. An extensive lysis of adhesions was undertake to mobilize the omentum from the anterior abdominal wall and the pelvis / adnexal structures. This adhesolysis took about 35 minutes. The tubes and ovaries were then removed using the Ligasure device to divide them from their vascular supply and adhesions to the pelvic sidewall.
 
The pelvis was irrigated. All surgical sites were inspected and found to be hemostatic. The CO2 was allowed to escape. The ports were left in place until after the vaginal repair work was completed, then removed.
 
Attention was then turned to the vagina. A diagnostic cystoscopy was performed using the 70 degree cystoscope and normal saline as a distension medium. An ampule of methylene blue was injected intravenous. Blue dye was observed to be egressing from the ureteral orifices, confirming bilateral ureteral patency.
 
Examination of the suburethral area revealed a dimpling of the scar toward the urethra. No obvious mesh was extruded through the mucosa, but there was a puckering of the scar.
 
The borders of the cystocele were identified, and the vaginal mucosa was injected with dilute vasopressin (20 units in 100 mL normal saline) in the midline to hydrodissect it away from the underlying fascia. The midline was incised with a 15 blade knife and the vaginal mucosa was dissected away from the underlying fascia with the Metzenbaum scissors. The mesh sling was palpated and mobilized medially toward the urethra / suburethral area away from the vaginal epithelium. The lateral pubovesicocervical fascia was then plicated at the midline with interrupted 2-0-vicryl sutures, thereby reducing the cystocele and building up the pubovesicocervical fascia between the urethra and the epithelium. The vaginal mucosa was trimmed and the vaginal incision was closed with interrupted 4-0 monocryl.
 
Attention was then turned to the posterior repair. The perineum was grasped with Allys clamps at 4 and 8:00 on the hymenal ring. The posterior vaginal mucosa was elevated with allis clamps and injected with dilute vasopressin. A diamond shaped wedge of skin was removed at the introitus. The vaginal mucosa was incised over the rectocele and the mucosa was dissected away from the peri-rectal fascia with a combination with sharp and blunt dissection.
 
2-0-vicryl sutures were used to plicated the lateral edges of the peri-rectal fascia in the midline, starting at the superior aspect of the rectocele, and working toward the perineum. This reduced the rectocele. The levator muscles were quite attenuated and brought to the midline with the repair for better pelvic floor support. No enterocele was noted.
The vaginal mucosa was trimmed sharply and the vaginal mucosa was closed over the rectocele with interrupted 4-0 monocryl. Additional figure-of-eight 2-0 vicryl sutures were required for complete hemostasis.
 
The bulbocavernosis and superficial transverse perineal muscles were isolated and reapproximated in the midline. Interrupted 2-0 vicryl sutures were placed to build up the perineal body.
 
At the end of the procedure, the both the cystocele and the rectocele was reduced and the gaping introitus was repaired.
 
Gloves and gown were changed and attention was returned to the abdomen. The abdomen was inspected and hemostasis of all operative sites was noted. Arista 1 gm was dispersed along the surgical dissections for some slight capillary oozing.

All laparoscopic ports and instruments were removed.




 
 



Comments (1)
Posted By Melanie Witt on 03-21-2018, 16:37:54
The codes seem correct - that for the sling revision would be 57287. I see no bundling issues here. Note that while Medicare allows the modifier -50 with 58661, CPT published that it was not allow the same year so do not be surprised if you a get paid on this code with no extra for the modifier -50.
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