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Posted By Dorine on 08-14-2020, 13:37:53 in Ob-Gyn
Hello Ob-Gyn group, my doctor took the patient to the OR for an exploration of the vaginal cuff as she is s/p 09/12/19 hysterectomy bilateral salpingectomy -his findings were left vaginal cuff separation, approximately 0.5 cm, pelvic hematoma - 6x4 cm , old suture appreciated at vaginal cuff. Op report reads: EUA revealed an intraabdominal vaginal cuff mass, the mass was mobile and firm to palpation, speculum placed in posterior fornix and vaginal cuff visualized with the assistance of rt angle retractors. Old suture visualized and removed w/o difficulty. Vaginal cuff was then bluntly dissected and opened with Carmalt's in a push and spread fashion. No purulent material noted from cuff, cuff was again inspected and no bleeding was noted at edges. irrigation was carried out until clear. Small amounts of vaginal bleeding was seen coming from behind the vaginal cuff. Arista was placed intravaginally, approximately 0.5 cm x 0.5 cm vaginal cuff opening appreciated w/ good hemostasis noted, instruments removed. I submitted this charge using 58999 and would like to confirm if this was the best coding choice and if so what code would be comparable, I was thinking I could use 57410 or 57200. Would you please advise as insurance is requesting a comparison code. Thank you so much!