Post

Hey Melanie,

I think this will be an unlisted procedure 58999. but I would like your opinion.

The excision code and the destruction code can not be used for vaginal cuff lesion or destruction. The codes we have are to be used for external excision and or destruction. Not for internal use.

Findings:
External Genitalia: Normal external genitalia, no lesions on vaginal side walls. Mucosa pink. 2cm pink lesion with small raised border in mid-portion of vaginal cuff.Acteo-white changes noted in this area as well.
 
Procedure in Detail:
Patient was met in the preoperative suite, where history and physical were updated and consent re-obtained verbally. The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. Patient was taken to the operative suite where general anesthesia was administered without difficulty. Patient was then positioned in the dorsal lithotomy position, with special attention to avoid exaggeration of flexion or extension of the legs. She was then draped in the normal sterile fashion.
 
The speculum was placed into the vagina, and acetic acid was applied. The above findings were noted. A lesion at the vaginal cuff was excised.
 
The CO2 laser was set up and tested with a power of 5. The laser was used to laser the lesion in a stepwise fashion, and excellent hemostasis was noted. Lidocaine and silvadene were applied to the area. All instruments were removed from the vagina. The patient tolerated the procedure well. Sponge, lap, needle and instrument counts were correct x 2. The patient will go to the recovery room in stable condition.

Thanks so much, Maria