Surgical Case #67 Appendix 8 385 Operative Report 1. Enlarged symptomatic fibroi
ID: 248762 • Letter: S
Question
Surgical Case #67 Appendix 8 385 Operative Report 1. Enlarged symptomatic fibroid uterus A17 Preoperative Diagnoses wweks 3. Menorhagia. 1. Enlarged symptomatic fibroid 2. 3. Menorrhagia. General endotracheal tube. ative Diagnosis: uterus. Anesthesia Type: Estimated Blood Loss: Procedures enefits and 300mL Laparoscopic-assisted robotic hysterectomy that was converted to total abdominal hysterectomy and bilateral tube removal and lysis of adhesions. e agreed to Performed: t of amniotic he abdomen nd guidance cket and ap- h was lightly sing a secoed the procedune The patient had a 12 to 14 week sized uterus with a particularly large pedunculated subserosal to intramural fibroid off the posterior aspect of the uterus. There were also significant omental adhesions. There were also adhesions of the lower uterine segment/cervix to her bladder consistent with her prior vertical C-section. She also has signs of tubal ligation noted. Both ovaries were normal. There was an ovulatory type cyst on the patient's right ovary. The appendix was not visualized. The remainder of the intra-abdominal cavity was visually normal. The uterus was also quite boggy consistent with adenomyosis obtained and rofile post pro- n) is mature we Procedure In Detail: The patient was taken to the operating room and was placed under general anesthetic. She was prepped and draped in normal sterile fashion and beanbag gel pads for robotic surgery. A time- out was called and agreed upon by all in the room. Her uterus was examined and appeared to be larger than was suggested by ultrasound, but also seemed to be relatively Exed to the anterior wall, which would have been consistent with her prior C-sections s of the large size was placed in the uterus the VCare through a vertical incision. Placement for ports was decided The VCare apparatu and sew into the cervix and the uterus did sound to the device was pushed all the way to the fundus and balloon blown up. When I was happy with placement it did seem to have adequate uterine mobility, we went from above placed our Veress supraumbilically in incision followed by a 10-mm d trocar and sheath. Intra-abdominal placement cor adhesive disease in the significantly enlarged uterus but did appear to be freely mobile and no other adhesions were noted to the sides or posteriorly, so the decision to continue with robotic procedure was made. All 3 arms were used and bipolar forceps reedle some (Continued on next page)Explanation / Answer
The CPT code for this case is 58150-22.
The procedure is 58150 denotes a total abdominal hysterectomy with or without removal of tube, wit or without remaval of ovary. In the case it was mentioned that it was a total abdominal hysterectomy with bilateral tube removal and lysis of adhesion. So the code should be 58150. However, from the procedure mentioned it appears that it was a complex procedure where the lysis of adhesion were extensive . It also took more than a usual procedure. From the description it apparently shows that the use of instruments were more. hence the modifiers 22 need to be added.
The the final code is 58150-22.
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