1. Tonya Davis
   Posted 9 months ago #
   

   Patient had hysterectomy on 5-18-11. She came to our office on 7-22-11 with pain following intercourse. Patient was taken to or on 7-25-11 for diagnostic laparoscopy and repair of vaginal cuff dehiscence. Findings were: Approximately 4cm defect in the vaginal cuff, extensive pelvic inflammation and several pockets of frankly purulent fluid collections. Needing help with cpt code and diagnosis codes. Thanks

2. SuperCoder
   Posted 9 months ago #
   

   I was almost going to answer. But, I thought it better to clarify one more thing. Can you plz elaborate the laparoscopic procedural documentation details of this?

3. Tonya Davis
   Posted 9 months ago #
   

   An infraumbilical vertical 5mm incision was made with a scapel. A trocar wa splaced into the abdominal cavity inder direct laparoscopic visualation. Pnumoperitoneum was created. A suprapubic midline trocar was placed within the site of the prior Pfannenstiel scar and an additional left lateral trocar was placed at the site of a prior trocar scar.The patient was placed in the Trendelenburg position. The small bowel was adherent to the vaginal cuff. Small bowell was gently detached from the peritoneal adhesions on the bladder and vaginal cuff. Care was taken to place no excess traction on the bowel. The vaginal cuff defect was exposed. Several pockets of pus were identified adn irrigated and evacuated. The pelvis was copiously irrigated. The vaginal cuff was closed with 6 interrupted 2-0 vicryl sutures. Attention was then turned back to the laparoscopy. The vaginal cuff was sealed.

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