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Posted By Maria on 12-26-2019, 07:03:13 in Ob-Gyn
Hello Melanie,

Please help with CPT codes. Dr has 58571,50715,58958,s2900

Thanks, Maria
 
A supraumbilical skin incision was then made approximately 22 cm above the pubic symphysis and a veress needle was introduced into this incision. Once proper placement was noted by physical examination and sterile water flowing easily into this incision then CO2 gas was insufflated into the abdomen at a maximum pressure of 15 mmHg. A 10/12 blunt trocar was then inserted through this incision and the Robotic camera verified proper placement of this port. Bilateral blunt robotic trocars were then placed 10 cm lateral and 15 degrees inferior lateral from the midline camera port. An additional left flank robotic port was placed 10 cm lateral and 15 degrees upward from the prior robotic port. A 10/12 accessory port was placed beneath the right costal margin. The patient was then placed in steep trendelenberg position and the robot was docked. The monopolar scissors were placed in the right robotic arm; bipolar fenestrated graspers in the left robotic arm and the double fenestrated graspers were placed in the third robotic arm.
 
45 minutes was taken doing lysis of adhesions of the ovary from the pelvis and sidewalls, and lysis of adhesions of the colon from the posterior uterus. Bilateral round ligaments were taken down with monopolar cautery and the retroperitoneal space was opened. The underlying ureters were visualized and the infundibulopelvic ligaments bilaterally were cauterized with bipolar cautery and cut with monopolar cautery. Due to dense fibrosis the ureter was traced from the pelvic brim to the bladder. The vesicouterine peritoneum was incised and the bladder was dissected off the lower uterine segment and cervix. The uterine vessels were then cauterized bilaterally with the bipolar and transected with the monopolar cautery. The cardinal and uterosacral ligaments were then cauterized with the bipolar and transected with the monopolar cautery. A posterior colpotomy was made at the level of the Vcare and brought around circumferentially freeing up the specimen, which was brought out through the vagina. The vaginal cuff was then reapproximated with 0 PDS in a running fashion, starting from either end and tying in the middle. The pelvis was then irrigated and the vaginal cuff was noted to be hemostatic. The infundibulopelvic ligaments were noted to be hemostatic as well. Frozen showed carcinoma and due to limited vision in the upper abdomen it was decided to open to stage the cancer. The instruments were then removed and the robot was undocked. The pneumoperitoneum was then evacuated and all trocars were removed. The 12 mm trocar fascia sites were reapproximated with a figure of eight stitch of 0 vicryl. All skin incisions were closed with a 4-0 vicryl subcuticular stitch.
 
A midline vertical skin incision was made from the symphysis pubis to up around the umbilicus. The incision was carried down to the fascia with the bovie cautery. The fascia was then incised and the incision was extended superiorly and inferiorly. The rectus muscles were separated in the midline. The peritoneum was identified and entered sharply, then carried superiorly and inferiorly with good visualization of the bladder.
 
The bookwalter retractor was then placed and attention was turned to the upper abdomen. The infracolic and supracolic omentum were carefully dissected off the transverse colon sharply and with assistance from the bovie cautery. The small bowel was then run from the ligament of treitz to the cecum.
 
The bowel was then packed back and attention was taken to the pelvis. The external iliac lymph nodes were then removed with the margins of resection being the genitofemoral nerve laterally, the ureter medially, midportion common iliac artery superiorly and distal circumflex iliac vein inferiorly. Once these nodes were removed then the paravesical space was identified and the obturator lymph nodes were removed from the external iliac vein down to the obturator nerve bilaterally. Attention was then taken to the left para-aortic lymph nodes. The ureter was placed on medial stretch and the margins of resection were the psoas muscle laterally, the aorta medially, 2-3 cm inferior to the renal vein being the superior margin and the common iliac artery inferiorly. All these nodes were removed with hemoclips and sharp dissection with good hemostasis.
 
The pelvis was thoroughly irrigated and found hemostatic.
 
Fallopian tube, left, left salpingo oophorectomy:
        Serous adenocarcinoma, high grade   (see comment)
        Maximum tumor dimension 0.4 cm.
        
    Ovary, left, left salpingo oophorectomy.
        Metastatic serous adenocarcinoma
        Maximum tumor dimension 5 cm    




Comments (1)
Posted By Melanie Witt on 01-04-2020, 15:46:47
This is tough one since he went from laparoscopic to open. I would agree with 58571 for the first part of the surgery, but do not agree with 50715 as he removed the tubes and ovaries and this part of the surgery would have involved tracing the ureters in any case. Also 50715 is an open procedure code, not laparoscopic so would not apply in this case. I would, however add a modifier -22 to 58571 for the time spent with the adhesiolysis. The path report shows only the left tube and ovary so does this mean right ovary had been previously removed - a good descriptive indications statement at the beginning would go a long way to explaining this surgery. There is no tumor debulking described in the above report so code 58958 is not correct - and we also do not know (because there is no indications statement) if this was recurrent cancer and not just initial cancer. He did do an open omentectomy and that would be code 49255 which has no bundling issue with 58571. As to lympadenectomy for staging, there is no open code for this procedure, only a partial sampling (38562) and it is not clear from his description if he did complete bilateral pelvic lymphadenectomy or unilateral for some of the nodes and bilateral for others.I would therefore report 38999 for the lymphadenectomy and compare the work to the laparoscopic code that would have otherwise applied for this case (38572).
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