garivo06 Posted Wed 05th of April, 2017 14:48:38 PM
What would be the best code for this scenario please
the operative report reads : laparoscopic resection of 38 cm pelvic mass right tube and ovary.
mass consistent with torsion
Additional ports were placed in the left side and the mass was grasped and held with tension to reduce any spillage. once the fluid was suctioned approx. 18.5 lt of fluid was suctioned out of the mass. the mass was noted to be somewhat torsed,it was untorsed. the ligasure devise was used to take the IP ligament and followed down to the peritoneal area followedby the utero ovarian ligament which was thickened.Once the mass was freed hemostasis achieved the abdomen and pelvis irrigated . at this point the mass as too large to place a 15 endocath bag noted to be grossly benign it was grasped and the incision slightly extended. the mass was delivered through this incision
path report : fallopian tube and ovary right salpingoophorectomy
fallopian tube acute and chronic salpingitis
Ovary benign hemorrhagic cyst with foci of flattened ephitelium consistent with hemorrhagic benign serous cystadenoma
SuperCoder Answered Thu 06th of April, 2017 05:35:53 AM
I would like to suggest Cpt code 58661 Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) for OP note as its seems appropriate for the given scenerio.
garivo06 Posted Thu 06th of April, 2017 16:48:15 PM
thank you I appreciate the prompt response.
SuperCoder Answered Fri 07th of April, 2017 04:38:06 AM