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Laparoscopic myomectomy and ablation of endometriosis and hysteroscopy

Sandra Posted Tue 22nd of December, 2015 17:26:19 PM

How would I bill?
Operative Lapraroscopy
laparoscopic myomectomy
ablation of endometriosis
Operative Hysteroscopy
Multiple Polypectomy
DX: Endometrial polyps
Stage I Endometriosis
Serosal Fibroid

SuperCoder Answered Wed 23rd of December, 2015 08:36:33 AM

Please provide complete Operative report to suggest CPT codes.

Sandra Posted Fri 15th of January, 2016 16:08:48 PM

preparing to undergo infertility therapy, noted on HSG with multiple filling defects suspicious for endometrial polyps. In addition, her history was significant for progressive dysmenorrhea suspicious for endometriosis, now for surgical evaluation. Under anesthesia revealed uterus, which of normal size, shape, contour, anteverted and mobile. There were no adnexal masses appreciated. Laparoscopy revealed a 2 cm anterior serosal fibroid, normal bilateral ovaries and fallopian tubes. There was a single powder-burn lesion in the posterior cul-de-sac, which was ablated. Chromotubation revealed bilateral fill and spill demonstrating patent tubes. The single serosal fibroid was removed after the endometriosis had been ablated. Operative Hysteroscopy revealed diffuse polypoid changes of the endometrium ranging in size from 1 to 2 cm. There were all resected with a Tru-Clear polyp morcellator. At the conclusion of the procedure, there was normal global cavity and bilateral Ostia noted, cleared for infertility therapy. Uterus was sounded and confirmed anteverted. Cohen Uterine manipulator was placed for chromotubation. Attention was then turned to the abdomen. A 5 mm incision was made at the base of the umbilicus and the laparoscope was placed under direct visualization. Intraabdominal placement was confirmed. Diagnostic laparoscopy with findings as noted above. Chromotubation was confirmed with bilateral tubal patency. Decision was then made to ablate the single ovarian cul-de-sac implant and hook monopolar cautery was used to ablate the lesion without difficulty. Hormonic scalpel was then utilized to excise the single 2 cm anterior serosal fibroid revealing an otherwise global normal uterus. At this time, laparoscopy was noted to be completed. Instruments removed from the abdomen. Attention was then turned to the vagina. A 2 mm smith and nephew hysteroscope utilizing normal saline as a distending medium was then palced through the cervix into the cavity and diffuse polyps as noted above. A 2.9 mm tur clear morcellator was then placed through the hysteroscopy and in a strile fashion, all polyps were resected.

SuperCoder Answered Mon 18th of January, 2016 09:16:12 AM

Thanks for the Query

I would suggest appropriate codes for the scenario Cpt 58558, 58545 and 58350.

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