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Posted By Mary Peabody on 04-13-2020, 14:30:34 in Ob-Gyn
Hello Melanie
A TAH/BSO Omentectomy and right pelvic lymphadencectomy was performed for ovarian cancer. Would you report this with 58150 38500-51 or 58951-52 (modifier 52 since no para-aortic lymphadenctomy was not performed.
POSTOPERATIVE DIAGNOSIS: High-grade malignancy of the right ovary,
final pathology pending
OPERATION: Exploratory laparotomy, total abdominal hysterectomy,
bilateral salpingo-oophorectomy, right pelvic lymphadenectomy,
omentectomy, cystoscopy, bladder repair, and control of pelvic hemorrhage
FINAL PATHOLOGIC DIAGNOSIS
A. Right adnexa, salpingo-oophorectomy:
- Ovary: Adenocarcinoma; see comment.
- Fallopian tube: No significant pathologic abnormality.
B. Uterus with left adnexa, total hysterectomy, salpingo-oophorectomy:
- Cervix: No significant pathologic abnormality.
- Endometrium: Endometrial polyps.
- Myometrium: No significant pathologic abnormality.
- Serosa: No significant pathologic abnormality.
- Fallopian tube: No significant pathologic abnormality.
- Ovary: No significant pathologic abnormality.
C. Right pelvic lymph nodes, dissection:
1. No tumor (0/4).
2. Reactive lymphoid hyperplasia.
D. Right common iliac lymph nodes, dissection:
1. No tumor (0/3).
2. Reactive lymphoid hyperplasia.
E. Omentum, 1 with nodule, omentectomy:
1. Surface adhesions.
2. Calcified organizing fat necrosis.
F. Omentum, #2, omentectomy: Surface adhesions.
A TAH/BSO Omentectomy and right pelvic lymphadencectomy was performed for ovarian cancer. Would you report this with 58150 38500-51 or 58951-52 (modifier 52 since no para-aortic lymphadenctomy was not performed.
POSTOPERATIVE DIAGNOSIS: High-grade malignancy of the right ovary,
final pathology pending
OPERATION: Exploratory laparotomy, total abdominal hysterectomy,
bilateral salpingo-oophorectomy, right pelvic lymphadenectomy,
omentectomy, cystoscopy, bladder repair, and control of pelvic hemorrhage
FINAL PATHOLOGIC DIAGNOSIS
A. Right adnexa, salpingo-oophorectomy:
- Ovary: Adenocarcinoma; see comment.
- Fallopian tube: No significant pathologic abnormality.
B. Uterus with left adnexa, total hysterectomy, salpingo-oophorectomy:
- Cervix: No significant pathologic abnormality.
- Endometrium: Endometrial polyps.
- Myometrium: No significant pathologic abnormality.
- Serosa: No significant pathologic abnormality.
- Fallopian tube: No significant pathologic abnormality.
- Ovary: No significant pathologic abnormality.
C. Right pelvic lymph nodes, dissection:
1. No tumor (0/4).
2. Reactive lymphoid hyperplasia.
D. Right common iliac lymph nodes, dissection:
1. No tumor (0/3).
2. Reactive lymphoid hyperplasia.
E. Omentum, 1 with nodule, omentectomy:
1. Surface adhesions.
2. Calcified organizing fat necrosis.
F. Omentum, #2, omentectomy: Surface adhesions.
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