Hello pt delivered 12/25/17 and came in today 1/8/18 for post postpartum hemorrhage. My question is what CPT do I use? MD preformed a suction D&C no dilation of cervix so I don’t think I can use the 59160. Here is part of the note:
PROCEDURE:
Graves speculum was placed. 0.3 cc of 2% Xylocaine with epi was injected into the anterior cervix. The cervix was then grasped with a single-tooth tenaculum and a paracervical block was given at 2:00, 4:00, 8:00 and 10:00 using 4 cc of 2% Xylocaine with epi. The cervix is patent to a 5 mm suction catheter attached to a 60 cc syringe. Suction curettage was performed ×1 pass and a moderate amount of tissue and blood was obtained. She tolerated the procedure well. The tenaculum was removed. There is no active bleeding at the end of the procedure in the patient denied any significant cramping.
*
Repeat transvaginal ultrasound was then performed and revealed an
Empty uterus other than small amount of fluid with the endometrial thickness now measuring 0.7 cm.
PROCEDURE:
Graves speculum was placed. 0.3 cc of 2% Xylocaine with epi was injected into the anterior cervix. The cervix was then grasped with a single-tooth tenaculum and a paracervical block was given at 2:00, 4:00, 8:00 and 10:00 using 4 cc of 2% Xylocaine with epi. The cervix is patent to a 5 mm suction catheter attached to a 60 cc syringe. Suction curettage was performed ×1 pass and a moderate amount of tissue and blood was obtained. She tolerated the procedure well. The tenaculum was removed. There is no active bleeding at the end of the procedure in the patient denied any significant cramping.
*
Repeat transvaginal ultrasound was then performed and revealed an
Empty uterus other than small amount of fluid with the endometrial thickness now measuring 0.7 cm.
Thank you,
:confused:Erika Espinoza CPC, COBGC