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Posted By Mary Peabody on 05-13-2020, 13:50:12 in Ob-Gyn
Hello Melanie,

would you report this procedure with an unlisted CPT 58578 and 58555? If unlisted which CPT would you crosswalk for pricing?
Preoperative diagnosis: Recurrent c-section scar ectopic pregnancies
Postoperative diagnosis: Same
Procedure performed:
1. Laparoscopic excision of residual c-section scar ectopic, laparoscopic c-section scar revision, hysteroscopy

Anesthesia: General endotracheal anesthesia
Indications:  G3P1011 h/o c-section scar ectopic x 2 who presents for consultation for c-section scar revision.
1. EUA: deferred, see BME from H&P
2. On laparoscopy, Thinned lower uterine segment. ~1 cm globular blue black mass along the right lateral aspect of c-section scar. Otherwise normal ovaries and fallopian tubes. Normal abdominal survey
3. On hysteroscopy, normal appearing uterine cavity
Medications: prophylactic antibiotics not indicated, marcaine for skin incision
IVF: 600 mL crystalloid
UOP: 300 mL (clear yellow at the end of the procedure)
EBL: 20 mL
Procedure in detail: The patient was taken to the operating room with IV fluids running. She was positioned on the OR table in the dorsal supine position. Sequential compression devices were placed and confirmed to be functioning. General anesthesia was induced without incident. The patient was then repositioned in low lithotomy position in Allen stirrups with care taken to avoid nerve compression. The patient was then prepped and draped in the standard fashion.
A foley catheter was inserted into the patient's bladder. A bivalve speculum was inserted into the vagina, and the cervix was identified. A single-toothed tenaculum was applied to the anterior lip of the cervix. The Humi uterine manipulator was placed without issue. The tenaculum and speculum were removed. Gloves were changed, and attention was turned to the abdominal portion of the case.
The base of the umbilicus was grasped with a Kocher and the skin was infiltrated with 0.25% marcaine with epinephrine. The base was then everted and and grasped with two towel clamps. The Veress needle was inserted until 2 pops were heard and felt. Initial insufflation pressure was appropriate. A vertical 10mm incision was made through the base of the umbilicus. The 10mm trocar was placed using the optiview trocar and the 10mm 0 degree laparoscope. Two 5 mm ports were placed in the right and left lower quadrants, and a 5 mm airseal port was placed in the RUQ, all under direct visualization. The peritoneal cavity was then examined with the above-mentioned findings. Using a 10mm suction, blood was suctioned from the pelvis and around the liver.
The c-section scar ectopic remnants were not initially visualized. The bladder was dissected off the lower uterine segment. A concurrent diagnostic hysteroscopy was performed using the wolfe hysteroscope. The uterine cavity and lower uterine segment was transilluminated with the hysteroscope and visualization laparoscopically revealed a thinned area in the lower uterine segment that was marked.
We then proceeded laparoscopically to dissect out this area using a a harmonic scalpel. The remnant of the ectopic pregnancy was identified and fully excised. The endometrium was entered to remove the residual ectopic tissue/scar and the thinned area of scar excised. The endometrium was reapproximated with 2-0 vicryl. The defect was then repaired in 3 layers of 0-Vlock.
The pelvis was irrigated and the surgical beds examined. Hemostasis at the surgical bed was confirmed.
The gas was evacuated from the abdomen. The ports were all removed.The 10 mm port fascial incision was re-approximated with 0 PDS. The skin incisions were reapproximated with 4-0 monocryl with buried interrupted stiches of 4-0 monocryl and skin glue.
The uterine manipulator was removed.The cervix was visualized. The tenaculum sites were confirmed to be hemostatic. The foley catheter was removed.
The patient was returned to the dorsal supine position. The patient tolerated the procedure well. Sponge, needle, and instrument counts were correct times two. The patient was extubated and taken to the post-anesthesia care unit in stable condition.
Specimens: possible ectopic remnant tissue
Complications: none
Drains: none
Dispo: to PACU, extubated, in stable condition

Comments (1)
Posted By Melanie Witt on 05-18-2020, 15:51:24
Yes, that would be your only option. For comparison I might look at
49321 with 10.02 RVUs, 58670 with 10.69 RVUs, 58662 with 20.63 RVUs, or 59510 with 22.79 RVUs. The physician, not you, needs to select the comparison code and be able to defend it with the payer. The range for what is described most likely falls somewhere in between the codes I have listed.
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