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Posted By Maria on 02-12-2021, 07:49:52 in Ob-Gyn
Hello Melanie,

This is a first for me.

I am not sure about dx codes for 49320. Surgery was negative. Should I use o99.891 , r10.2, r11.2 ? What about current twin pregnancy? Should I add it on also?


Patient is a 31y.o. gravida 5 para1011 female. The patient is here for a scheduled laparoscopic unilateral salpingectomy for ectopic pregnancy with possible unilateral oophorectomy. Ectopic pregnancy is suspected and pt currently has an intrauterine twin pregnancy. She was seen in the ED after initially being denied at an abortion clinic due to them having suspicion for an ectopic pregnancy. The pt had symptoms of intense RLQ pain, amenorrhea, and N/V and a positive pregnancy test. She denies CP/SOB/ab pain/dysura or a change in discharge.

US 2/9/2021 A limited transabdominal ultrasound did not provide optimal
visualization. A transvaginal exam was performed to better evaluate the
pregnancy. An intrauterine live dichorionic twin pregnancy was observed. A complex fluid collection in the right ovary measuring 1.6 x 1.3 x 1.8 cm,
likely a corpus luteum. A second complex fluid collection also surrounded
by "ring of fire" vascularity adjacent to and independent from the right
ovary measuring 2.3 x 2.4 x 2.3 cm, that may represent an ectopic
pregnancy or a possible second corpus luteum. Complex free fluid also
visualized in the posterior cul-de-sac.

Pre-operative Diagnosis:
1. Di/di intrauterine pregnancy
2. Suspected ectopic pregnancy

Entry to the abdomen was performed using a Hassan technique to avoid uterine perforation of the gravid uterus. Once entry was secured, a 10mm trocar was then introduced into the peritoneal cavity with confirmation of placement performed with laparoscopic visualization. The abdomen was insufflated. Diagnostic laparoscopy was performed with the above noted findings. Under direct visualization, two 5mm accessory ports were placed in the right and left lower quadrants without difficulty. At this point in the procedure, the uterus was elevated and both fallopian tubes and ovaries were visualized bilaterally. There were no noted abnormalities.

Following completion of the procedure all instruments were removed from the patient’s abdomen, and pneumoperitoneum evacuated. All ports were removed from the abdomen. The fascia of the 10mm port was closed with 0-vicryl in a figure of 8 fashion. The skin incisions were closed using a 3-0 monocryl. Steri strips were placed over the incisions. Following removal of all instruments from the vagina, all sponge, lap, and needle counts were correct x2. The patient tolerated the procedure well. She was awoken from general anesthesia and transferred to recovery in stable condition.

Thank you!
 












Comments (1)
Posted By Melanie Witt on 02-15-2021, 14:44:51
Did you consider Z03.79 as this is a condition ruled out which was the case here. While there are twins present, that is not why the diagnostic laparoscopy was performed and also not for projectile vomiting. I would go with the Z code and the R code for pelvic pain in this instance.
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