Melissa Posted Sat 18th of January, 2020 12:30:34 PM
Hello, I am not sure what to code for this Out Patient Procedure note: "The patient was taken to the OR under general anesthesia; she was examined confirming the presence of a 4cm right Bartholin's cyst which had been previously incised in the office; the incision had been packed in the office and the packing was removed in the OR. The cyst wall had been completely resected in the office; the incision was found to have one actively bleeding vessel which was then suture ligated and hemostatis assured. The incision was closed in deep layers " Any assistance would be much appreciated
SuperCoder Answered Mon 20th of January, 2020 09:08:03 AM
Thanks for your question.
As per the limited documentation, the patient was examined and confirmed with the presence of 4cm Bartholin’s cyst therefore, code 56740 Excision of Bartholin's gland or cyst should be used.
Code 56740 suggests that after the provider administers anesthesia, he places the patient in the dorsal lithotomy position and preps and drapes the perineum. The provider examines the rectal and vaginal area to identify the area of the gland or cyst. The provider retracts the labia and incises the vaginal mucosa directly over the opening into the Bartholin's gland. The provider retracts the surrounding tissue to expose the wall of the gland, which he then carefully excises to avoid excessive bleeding from the pudendal artery. Because of the extensive blood supply in this area, he controls bleeding using either electrocautery or sutures along the bed of the gland. If the provider removes a cyst rather than the gland, he makes a wedge–shaped vertical incision in the vaginal mucosa of the cyst. The provider uses hemostats to grasp the cyst wall, and he uses scissors to dissect it from its bed. He irrigates the cystic cavity with normal saline. He may also insert a small closed suction drain into the wound and suture it in place. He then closes the incisions with sutures.
Hope this helps.
Melissa Posted Mon 20th of January, 2020 09:25:23 AM
Thank you. i am still a bit confused. I am wondering if this should be coded as a return to surgery, since he says the "cyst wall had been completely resected in the office" and then he saw the patient in the OR, where the packing was removed and the active bleeding was ligated closed in deep layers? Also was the full procedure done again in the OR even if the cyst had already been removed in the office?
SuperCoder Answered Tue 21st of January, 2020 08:50:39 AM
Thanks for your question.
The documentation do suggest that the 'cyst wall had been completely resected in the office'. Therefore, in the OR the patient had the packing removal and ligation of vessels. So, the excision of bartholin's cyst will not be coded again.
If the patient had unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period then modifier 78 will be appended with the code.
Can you please provide the detail of ligation of vessel i.e. vein or artery so that we can provide you with the appropriate code.