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Posted By ob/gyn on 03-29-2018, 16:25:39 in Ob-Gyn
Any suggestions on how this surgery should be coded? The Dr. told me a rep for the injections gave her the code 51715. The patient had this 11 times, is that code for individual injections?

SURGEON: Dr. A
***Chart Document***

DATE OF SERVICE: 03/26/2018
ASSISTANT: Dr. B

Preoperative Diagnoses:
1. Pelvic prolapse, capacious enterocele, intrinsic sphincter
deficiency.
2. Incontinence, low-pressure urethra.

Postoperative Diagnoses:
1. Pelvic prolapse, capacious enterocele, intrinsic sphincter
deficiency.
2. Incontinence, low-pressure urethra.
3. Vaginal atrophy.

Procedures:
1. Diagnostic cystoscopy.
2. Enterocele repair with native tissue.
3. Periurethral bulking with Durasphere.

Anesthesia: General anesthesia via LMA and local anesthesia to the
incisional sites, 1% lidocaine 54 cc.

Findings: Low-pressure urethra, ISD, incontinence, and capacious
enterocele and vaginal atrophy.

Complications: None.

Estimated Blood Loss: 25 cc.

Urine Output: 400 cc.

Pathology Specimens: Vaginal mucosa.

Condition: Stable, urinary catheter.

Indications: Postop monitoring and anticipated urinary retention from
periurethral bulking.

Description of Operation: The patient was brought into the operating
room,
placed supine on the operating room table where general anesthesia via
LMA
was administered in the usual fashion. The patient was placed in the
dorsal lithotomy position, prepped and draped in usual fashion for
vaginal
surgery. A large capacious enterocele was noted. Two Allis clamps were
placed on the vaginal apex for downward traction. A 1% lidocaine with
epinephrine was instilled into the vaginal mucosa. The vagina was
incised
in the midline essentially from 1 fingerbreadth from the urethral meatus
to
the hymenal ring. The vesicovaginal fascia was reflected by blunt and
sharp dissection.

Because of her age, it was elected not to proceed to sacrospinous
ligament
suspension or graft placement. An in situ native tissue enterocele
repair
was performed. Using a free sponge, a peanut Metzenbaum scissors and my
finger, the vesicovaginal and rectovaginal tissue was reflected
superiorly.
Interrupted 0 Vicryl sutures were placed laterally plicating the levator
muscles to the midline. The excess vaginal tissue was excised. It was
elected not to perform perineorrhaphy for the same reasons as noted
above.
The vaginal tissues were then reapproximated with a running 2-0 Vicryl
suture.

Next, attention was directed towards periurethral bulking and cystoscopy.
Cystoscopy was performed with both a 30- and 70-degree lens documenting
the
absence of any bladder injuries. Both ureteral orifices found to be
patent
of clear yellow urine. Using the Durasphere injectable needle with
cystoscopy and urethroscopy, the urethrovesical junction was identified.
Durasphere of 6 cc in 6 separate syringes, 1 cc each were injected into
the
periurethral tissue on the patient's right side. Five 1 cc injections of
Durasphere bulking agent were injected on the right side. Cystoscopy was
again performed with a 30- and 70-degree lens. No evidence of bladder
injury. A transurethral Foley was placed. These Durasphere injections
were performed under direct visualization using cystoscopy with the
camera.
The patient was then reversed from anesthesia, extubated, and transferred
to the recovery room.
Comments (1)
Posted By Melanie Witt on 03-30-2018, 20:58:11
Per CPT the average number of injections is 4 when this procedure is performed, but it would include any number required to ensure coaptation of the urethra. So you can bill 51715 only once. For the other he did a sacrospinous ligament fixation to repair the enterocele and that code would be 57282.
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