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Posted By dawn b on 12-29-2017, 16:28:58 in Ob-Gyn
attached H&P with OP note
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  1. tc.pdf
Comments (2)
Posted By dawn b on 01-03-2018, 10:11:34
Thank you! I was leaning towards the gyn cpt codes for this too.
Posted By Melanie Witt on 01-02-2018, 17:56:41
Based on the op note this was a supracervical abdominal hysterectomy with BSO. The fetus was removed along with the uterus, and not removed separately. There were dense adhesions, but their removal was not documented to an extent that would warrant the addition of a modifier -22 in my opinion. Therefore, coding for this would be 58180 and the diagnoses would be:
O02.1 Missed abortion
O44.01 Complete placenta previa NOS or without hemorrhage, first trimester (the op note says 13-14 weeks but unless the path report says 14 weeks 0 days or more go with the first trimester designation)

They are mention possible placenta accreta but not confirmed unless the path report mentions it and if so include that diagnosis as well.
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