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Revision of Uterus along with Recanalization of Cervix with Cervical Stent Placement

Does anyone know the correct CPT code to use for the following procedure?

PROCEDURE IN DETAIL: Patient was taken to the operating room and was placed in dorsal lithotomy position and was prepped and draped in standard surgical fashion.
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Intra-abdominal entry was not made in this patient. The patient was examined under anesthesia. It appeared that patient had a rather aggressive LEEP in the past. Her cervix was virtually absent. When we placed the duck billed speculum in the vagina we could not find a cervix or a cervical opening.
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Intraoperative ultrasound was then performed which demonstrated a large collection of blood within the uterus with complete occlusion of the presumed cervical endocervical canal.
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Patient wanted to have kids and therefore a recanalization procedure along with division of the uterus was needed.
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Subsequently, multiple lacrimal duct probes were taken and a tentative cervical canal was formed with lacrimal duct probe and under ultrasound guidance an opening into the uterus was made in a transvaginal fashion. As soon as we entered the uterus, old hematometra was evacuated, evacuating approximately 200 mL of blood under ultrasound guidance. This blood was old and altered. Subsequently, we needed to suture the upper vagina to the endocervical canal with multiple interrupted stitches and the minimal cervical tissue that was found was subsequently sutured onto itself with a cervical stent. A red rubber Foley catheter was subsequently inserted into the uterus and was passed through the vagina to keep the newly created endocervical canal open.
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The red rubber Foley catheter was basted to the right thigh of a patient. Multiple intraoperative pictures with ultrasound guidance were taken and were uploaded to the patient’s chart.

I have NO idea. My surgeon wants me to use 58540 but that does not seem correct to me.

Any help is greatly appreciated!! 😮

Medical Billing and Coding Forum

double uterus code question

I have a recent chart that has a double uterus and double cervix but does not include a double vagina. I am not sure what code to use. Q51.1 seems to me they include a double vagina also. I am not sure how that would work but its how I understand the code description. I can not find anything to give me a clear definition. Can someone explain this code description for me? I would really appreciate it. Thanks in advance.

Medical Billing and Coding Forum

Uterus weight for hysterectomy

So I’ve been trying to find clarification online…but haven’t found anything so far.
I’m new to OB/GYN coding and have found I have a problem reading a little too much in between the lines and making sure my codes fit EXACTLY. With that being said:
On my path report the pathologist states she received "multiple fragments of uterine tissue that together weigh 367g and measured…."
My question:
I know for LAVH codes (and a few others) they are dependent upon the weight of the uterus…as the path statement above states, it’s not JUST the uterus weight they listed but rather the TOTAL weight of the tissue. Would I just code to the lesser 58552 (uterus less than 250g) if the path report doesn’t specifically state the uterus itself was 250g+?

I’m billing for our private dr who did this as an outpatient procedure at a big hospital here, the hospital did the path. I don’t know if we can request going forward that the uterus be weighed independently for coding purposes???

Thanks in advance!! I’m sure I’ll be seeing you guys around quite frequently now that I’ve found this forum! Excited to learn as much as I can!

Medical Billing and Coding Forum