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Posted By Maria on 03-07-2019, 10:02:42 in Ob-Gyn
Hello Melanie,

Would you please tell me if I am close to the correct coding for this procedure? Codes at the bottom after report.

SPECIMEN:
Uterus, cervix, bilateral fallopian tubes and ovaries, bilateral pelvic and right aortic lymph nodes

A supraumbilical skin incision was then made approximately 22 cm above the pubic symphysis and a veress needle was introduced into this incision. Once proper placement was noted by physical examination and sterile water flowing easily into this incision then CO2 gas was insufflated into the abdomen at a maximum pressure of 15 mmHg. A 10/12 blunt trocar was then inserted through this incision and the Robotic camera verified proper placement of this port. Bilateral blunt robotic trocars were then placed 10 cm lateral and 15 degrees inferior lateral from the midline camera port. An additional left flank robotic port was placed 10 cm lateral and 15 degrees upward from the prior robotic port. A 10/12 accessory port was placed beneath the right costal margin. The patient was then placed in steep trendelenberg position and the robot was docked. The monopolar scissors were placed in the right robotic arm; bipolar fenestrated graspers in the left robotic arm and the double fenestrated graspers were placed in the third robotic arm.
 
Bilateral round ligaments were taken down with monopolar cautery and the retroperitoneal space was opened. The underlying ureters were visualized and the infundibulopelvic ligaments bilaterally were cauterized with bipolar cautery and cut with monopolar cautery. The vesicouterine peritoneum was incised and the bladder was dissected off the lower uterine segment and cervix. The uterine vessels were then cauterized bilaterally with the bipolar and transected with the monopolar cautery. The cardinal and uterosacral ligaments were then cauterized with the bipolar and transected with the monopolar cautery. A posterior colpotomy was made at the level of the Vcare and brought around circumferentially freeing up the specimen.
 
The vaginal cuff was then reapproximated with 0 PDS in a running fashion, starting from either end and tying in the middle. Bilateral external iliac lymph nodes were then removed with the margins of resection being the genitofemoral nerve laterally, the ureters medially, midportion of the common iliac artery superiorly and the distal circumflex iliac vein inferiorly. All nodes were removed through an Endo Catch bag through the 10/12 port. Locating the continuation of the hypogastric vessel and placing it on medial stretch then developed the bilateral paravesical spaces. The overlying obturator nodes were removed from the external iliac vein down to the obturator nerve bilaterally. These nodes were also placed in an Endo Catch bag and brought out through the 10/12 port.
 
The peritoneum was then opened along the common iliac artery and up the aorta for para-aortic lymphadenectomy. Bedside assistant was used to retract the ureter laterally and tent the peritoneum. Right common iliac lymph nodes were removed from the external iliac after the bifurcation of the aorta and then right para-aortic lymph nodes were removed from the bifurcation up to the inferior mesenteric artery. All nodes were removed through the Endo Catch bag.

The pelvis was then irrigated and the vaginal cuff was noted to be hemostatic. The infundibulopelvic ligaments were noted to be hemostatic as well. The instruments were then removed and the robot was undocked. A 4-5 cm incision was made 2 finger breadths above the pubic bone. bovie carried this down to the fascia and the fascia was opened. The rectus was split in the midline and peritoneum was entered. The uterus with ovaries was then removed. The muscle was reapproximated with 0-vicryl x 2. The fascia was closed with 0-vicryl x 2. The skin was closed with 4-0 vicryl. All trocars were removed. The 12 mm trocar fascia sites were reapproximated with a figure of eight stitch of 0 vicryl. All skin incisions were closed with a 4-0 vicryl subcuticular stitch. Steri-strips were placed as well as bandages. The vagina was examined and noted to have tears on sidewalls. 0- vicryl in multiple layers was used to close the defects. The vagina was examined with sponge sticks x 2 and noted to be thermostatic. Count correct x 2. Taken to RR.

Path was malignant uterus. Uterus 212 grams weight. 2 Para lumph nodes removed

My codes 38572,22 ,58571 & S2900

Dr wants 49000 , 57200, 38572 and 58571.

I don't think the 49000 is appropriate as I think this is more or less a mini lap. Method removal uterus and ovaries. . Only add mod 22. Dr states Exploratory laparotomy

Also, the 57200 I don't agree with as tears were caused by surgeon. Kinda like you broke if, you fix it.. Dr does call this Complex closure of vaginal bilateral sidewall tears.

Am I close to correct CPT codes and my way of thinking?

As Always Thanks,

Maria
 
Comments (1)
Posted By Melanie Witt on 03-14-2019, 17:03:07
You are correct, this was a mini lap to remove the organs and as such does not constitute a separate diagnostic laparotomy. And although the procedure was done for malignancy, a radical was not performed so code 58571 is correct for the hysteroscopy. For the bilateral total lymphadnectomy with para-aortic lymph nodes the code is 38572, but as it is a bilateral code and I see not extensive additional work in getting the nodes out than would be expected, a modifier -22 is not warranted on this code in my opinion. You can bill S2900 but you won't get paid anything for using the robot - this code is just for information. The repair of the lacerations, which probably were caused during the surgery would be included and not billed separately - in order to bill 57200, he would have to have documented that the lacerations were there prior to surgery and it was a planned procedure. You can try billing this procedure if your payer insists, but I seriously doubt you will get paid.
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