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laproscopic hys w/ sapingo oophorectomy and bilat lymphandectomy w/ mini lap for

Lynn Posted Sun 18th of October, 2015 16:03:07 PM

They did a mini lap for specimen retrieval My doc want to code as laparotomy as opposed to laproscopic. Would this be appropriate 58200 ?

SuperCoder Answered Mon 19th of October, 2015 02:14:26 AM

It is not clear from the question whether to code cpt code 58200 or not. Please send the full operative note, as cpt code 58200 represents:
Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s)

Lynn Posted Mon 19th of October, 2015 06:28:42 AM

Procedure in Detail
The patient was brought to the operating room after consents were verified.Prophylactic antibiotics with Cefoxitin and subcutaneous heparin were given. General anesthesia was administered without difficulty. Patient was positioned with the Tren-Guard positioning system in dorsal lithotomy in bluefin stirrups. Her arms padded at the wrists and elbows and her arms were tucked with attention to no stress on joints or nerves. She was placed in steep trendelenberg and noted not to slide on the table and to have adequate airway pressures. A oro-gastric tube was placed on suction. She was returned to level position. She was then prepped and draped in the normal sterile fashion. A foley catheter was placed under sterile conditions.

A Zumi uterine manipulator with a small-size KOH colpotomy ring was placed for uterine manipulation.

Attention was turned to the abdomen. A 12 mm midline incision was made 3 cm above the umbilicus. Blunt and sharp dissection were used to reach the fascia which was elevated with two kocher clamps and incised. The Hassan port was then placed under direct visualization. The camera was placed to verify entry into the abdominal cavity.

The abdomen was filled with CO2 gas up to 22 millimeters of mercury pressure due continued leaking from the hassan port. Laparoscopic survey was carried of the pelvis and upper abdomen. The remaining ports were inserted under laparoscopic guidance using an 8-millimeter robotic port on the right and left lower quadrant and left upper quadrant, and then a 12-millimeter assist port was placed in the right upper quadrant.

The Da Vinci system cart was docked to the patient from the side position without difficulty. Operating instrument included monopolar scissors in arm 1, the PK Bipolar in arm 2, and Prograsp in arm 3. At this time pelvic washings were obtained.

Attention was turned to the pelvis. Adhesions from the sigmoid to the uterus were taken down with electrocautery. The left retroperitoneal space was opened by incising the lateral and parallel to the infundibular pelvic ligaments and the retroperitoneal spaces opened with blunt and sharp dissection. The ureter was visualized and retracted carefully from the surgical field. At this time, a dissection of the pelvic lymph nodes was carried out, boundaries include the bifurcation of the iliac vessels superiorly and the anterior division hypogastric artery, posterior boundary was the obturator nerve, adn the distal boundrary was the deep circumflex iliac vein all of which were carefully isolated and preserved. Lymph nodes were placed in each specimen retrieval bag separately for removal through the assist port.

The infundibulopelvic ligament was identified and ureter was identified well below. A peritoneal window was made under the IP ligament. The IP was then sealed four times and divided. The round ligament was sealed and divided. The uterine artery was then skeletonized, sealed and divided. The vesicouteruine fold was incised and the bladder flap was created and bladder mobilized. Bleeding was noted from a branch right uterine artery. The round ligament was sealed and divided. The bladder was well removed from the lower uterine segment. The branch of right uterine artery was sealed.

Attention was then turned to the right pelvic lymphadnectomy. The right retroperitoneal space was opened by incising the lateral and parallel to the infundibular pelvic ligaments and the retroperitoneal spaces opened with blunt and sharp dissection. The ureter was visualized and retracted carefully from the surgical field. At this time, a dissection of the pelvic lymph nodes was carried out, boundaries include the bifurcation of the iliac vessels superiorly and the anterior division hypogastric artery, posterior boundary was the obturator nerve, which was carefully isolated and preserved. Lymph nodes were placed in each specimen retrieval bag separately for removal through the assist port.

The infundibulopelvic ligament was identified and ureter was identified well below. A peritoneal window was made under the IP ligament. The IP was then sealed four times and divided. The broad ligament was taken down with electrocautery. The right uterine artery was skeletonized, sealed and divided. The colpotomy incision was made at the apex, and incision extended circumferential along the colpotomy ring using monopolar scissors. The adnexa were separated from the uterus, but the uterus was not able to be removed from the vagina due to its size and the narrow pelvic inlet. The adnexa were placed in separate bags. The assist port was then closed using the Carter-Thomason device with 0 Vicryl suture. The Da-Vinci instruments were removed and the cart was undocked. The robotic ports were then removed. The port sites were closed with 4'0 monocryl. 0.25% marcaine was injected.

Cystoscopy was then performed. No defects in the bladder done, trigone, or the lateral walls were noted. Good flow of the urine was noted from both ureteral orifices. The vagina was inspected and a bleeding 1 cm right vaginal wall laceration was noted. It was repaired with 3 interrupted sutures of 3'0 chromic were placed with good hemostasis noted.

Due to inability to remove the uterus intact through the vagina, decision was made to proceed with mini-lap.

A 9 cm vertical incision was made scalpel and carried through to the underlying layer of fascia with Bovie. The fascia was incised in the midline, and the incision extended superiorly and inferiorly. The peritoneum was elevated and then entered sharply, and the peritoneal incision was extended superiorly and inferiorly. A medium Alexis retractor was placed. The Bookwalter self-retaining retractor was placed for additional retraction, and the bowel was packed loosely back with care taken not to place excess traction on the bowel vasculature or pelvic sidewalls. The uterus was then removed. The vaginal cuff was grasped with long instruments and closed with figure of eight sutures of 0 vicryl. Additional sutures were placed for hemostasis. The pelvis was irrigated.
The vaginal cuff was inspected and found to be intact and dry.

The midline incision was closed with 1-prolene in a running in modified smead jones fashion. The subcutaneous tissue was irrigated. A #10 JP drain placed through a separate stab incision into the subcutaneous space. The subcutaneous tissue was re approximated with 3-0 chromic suture. Deep dermals with 4-0 vicryl were placed. The skin was closed with 4-0 Monocryl in a subcuticular fashion. Steri-Strips and a sterile dressing were applied. 0.25% marcaine was placed.

SuperCoder Answered Tue 20th of October, 2015 01:58:55 AM

After reading the operative report, it seems like that incision was performed just to remove the specimen which was not able to remove through laparoscopic port incision. So it will not be considered as a separate procedure. you need to code it as laparoscopic only. Bill CPT code 58548 (Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed)

Thankyou

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