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58571 TLH vs 58552 LAVH

Tammy Posted Mon 18th of January, 2016 13:53:23 PM

please let me know. we billed a 58571 but office thinks 58552?

The robot was docked in the typical fashion after patient was placed in steep trendelenburg. Attention was first turned to the patient's right side. Ureters were identified bilaterally. The right infundibulopelvic ligament was cauterized and transected and this dissection was taken along the mesosalpinx to the level of the uterus. The round ligament was then cauterized and transected. The right ovary was peeled away from the sidewall with sharp and blunt dissection. The vesicouterine peritoneum was identified and the anterior and posterior leaflets of the broad ligament were separated. The bladder was dissected off the anterior aspect of the uterus with some scar tissue noted. The uterine vessels on the right side were skeletonized and cauterized and transected. The same procedure was repeated on the patient's left side. Of note, on the left side, the round ligament was slightly adherent to uteroovarian ligament. The remainder of the bladder dissection occurred at this time. An incision was made anteriorly and the cervix was amputated from the vagina in a circumferential fashion. The uterus was removed vaginally. The vaginal cuff was closed in a running fashion with two V loc sutures. Irrigation was performed. Pneumoperitoneum was taken to 6 and no additional bleeding was noted. The bladder was filled retrograde with methylene blue and no intra-abdominal spillage was noted. Floseal was placed. Excellent hemostasis was noted. Sponge and needle counts were correct.

SuperCoder Answered Tue 19th of January, 2016 01:45:07 AM

AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) ( for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail for more information.

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