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I’m officially stumped!

I hope someone can shed a little light or at least point me in a direction on this case.

Two of my Urologists also do Uro/Gyn, and in this case, one of them was called in to a Gyn’s case – she was doing a myometrium repair and found dense abdominal adhesions from the cervix and uterus to the bladder dome and posterior wall. He used Metzembaum scissors to dissect and lyse all the adhesions off the bladder.

I am having a heck of a time finding a suitable code. It was an open procedure, so that rules out all laparoscopic codes. 44005 doesn’t fit because it wasn’t intestinal. The only other option I can think of is the solo E&M code, because he did dictate a full intra-op consult.

Anyone have any insight?

Thank you!!!

Medical Billing and Coding Forum

CPT help with Operative report….I’m stumped

I have an operative report for a procedure that my providers did for one of my patient’s, and I cannot figure out how to go about coding this one.

PREOPERTIVE DIAGNOSIS: Uterine perforation with hemoperitoneum.

POSTOPERATIVE DIAGNOSIS: Uterine perforation with hemoperitoneum.

DESCRIPTION OF PROCEDURE: Operative laparoscopy with coagulation of bleeding perforation site and evacuation of 600 mL of hemoperitoneum.

The doctor sent me a message regarding the procedure:

Pt was seen for acute abdomen, transfused blood. CT showed hemoperitoneum- active bleed from uterine defect. We did diagnostic laparoscopy (open), evacuated hemoperitoneum, coagulated uterine defect/bleeder, pt left same day in the afternoon.

I thought about possibly using code 59151, but I am not sure that is correct. Any help would be much appreciated!!

Medical Billing and Coding