I haven’t coded man OB/GYN cases. I don’t know what G5, P3 refers to. Can anyone help me with this? I believe the dx should be D25.2, R87.619, Z80.41, but should I add a dx for enlarged uterus? I don’t see where that is a symptom of the subserous uterine but I am not sure if I should add or not. For the procedure I thought maybe 58571, 00846 but I really have no idea. Thank you!!

A 43 year old, G5, P3 presented with complaints of pelvic pain with heavy blood clots and spotting between her menstrual cycles. Patient also has dysfunctional uterine bleeding. She has a family history of ovarian cancer in a maternal aunt.

PREOPERATIVE DIAGNOSIS: Symptomatic uterine fibroids, pelvic pain.

POSTOPERATIVE DIAGNOSIS: Symptomatic subserous uterine fibroids, pelvic pain.

OPERATION PERFORMED:
1. Laparoscopic assisted total vaginal hysterectomy with bilateral salpingectomy (robotic assisted).
2. Intraoperative cystoscopy.

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: 25 CC

URINE OUTPUT: 135 CC
DRAINS: Foley discontinued at the end of the case.
FLUIDS: Normal saline at 125 an hour.

INDICATIONS: 43 yr. old, G5, P3, who presented with daily mid-abdominal and central pain. Found on imaging to have a 5 cm, left-sided fibroid, additionally complaining of heavy bleeding and intermenstrual spotting. She has a history of abnormal PAP smears and cryotherapy to the cervix in the 90’s.

FINDINGS: Normal external female genitalia. Grossly enlarged uterus with a fibroid situation on the left side of the uterine fundus and sidewall, normal ovaries and fallopian tubes bilaterally, intact bladder with bilateral efflux of indigo carmine dye from the ureters following the procedure.

DETAILS OF PROCEDURE: Patient taken to the OR and placed under general endotracheal anesthesia. Foley catheter inserted and a moistened sponge stick with a pneumo occlude balloon at 45cc of air was placed intravaginally.
8 mm incision placed with the Veress needle inserted for an opening pressure of 1. CO2 was insufflated to a pressure of 20. The camera was inserted and the above intra-abdominal findings were noted. Right and left lower quadrant ports were placed under direct visualization, 8 mm in size. The robot was then docked and the procedure began on the patient’s left-hand side. The fibroid on the left side did obscure the right uterine vessels, which were tortuous across the unction of the fibroid.
The bladder flap was created and the Harmonic Scalpel was drilled into the vagina on the left hand side before switching instruments to complete the hysterectomy on the right. The scalpel was used to create the colpotomy. The ProGrasp was then used and allowed the cervix to be removed from the vagina. With direct visualization from the camera, the tenaculum was used to grab the uterine cervix, while removing the balloon and sponge, the uterus and cervix and fallopian tubes were pulled into the vagina to maintain the pneumoperitoneum. The uterus weighed 238 grams. The vaginal cuff was closed. Hemostasis was noted at all times, the robot was undocked and at the bedside. The procedure was complete and ports were removed.
The cystoscopy was then undertaken with a 70 degree cystoscopy. Bilateral efflux of indigo carmine dye from the ureters and an intact bladder was noted. Bladder drained and foley catheter was left. Patient taken to PACU in stable condition.