FGS Hysterectomy 1 Slide26 - AAPC

Documentation Dissection

PREOPERATIVE DIAGNOSIS: 1. Endometrial cancer, grade I.

POSTOPERATIVE DIAGNOSIS: 1. Endometrial cancer, grade I |1|.

PROCEDURES: 1. Examination under anesthesia.

2. Total abdominal hysterectomy and bilateral salpingo-oophorectomy |2|.

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: 200 mL.

COMPLICATIONS: None.

SPECIMEN: Submitted to Laboratory labeled as uterus, tubes, and ovaries.

FLUIDS ADMINISTERED: 4 liters of crystalloid.

TRANSFUSIONS: None.

DRAINS USED: Foley catheter

COMPLICATIONS: None.

DESCRIPTION OF THE PROCEDURE: She was taken to the operative suite and placed under general anesthesia. Once anesthesia was obtained, she was converted to a frogleg position. An examination under anesthesia was obtained but was relatively uneventful.

The abdomen, perineum, and vagina were prepped and draped in a sterile fashion. A pfannenstiel skin incision was made, the dissection was carried down through subcutaneous tissue, fat and fascia with electrocautery |3|. The peritoneum was elevated and entered sharply.

We then performed an intra-abdominal exam. The peritoneum over the left and right paracolic gutter was normal. Surface of the left spleen and hemidiaphragm were normal. Surface of the liver and right hemidiaphragm were normal. I could not palpate the gallbladder. There was no paraaortic adenopathy.

Omentum was normal. Examination of the pelvis revealed a slightly enlarged uterus. There was a benign-appearing mass on the left ovary. The right ovary was normal. There was no suspicious adenopathy. The Bookwalter retractor was placed. Bowel was packed into the upper abdomen. The left round ligament was transected with electrocautery. The retroperitoneal space was opened and developed. The ureter was seen. The ovarian vessels were isolated, crossclamped, transected, and ligated x 2. Similarly, the right round ligament was transected with electrocautery. The retroperitoneal space was opened and developed. The ureter was seen. The ovarian vessels were isolated, crossclamped, transected, and ligated x 2 with 0 Vicryl. Bladder flap was taken down sharply with electrocautery. In a successive manner, the uterine artery, the uterosacral ligament, and the cardinal ligament were crossclamped with curved Heaney clamps |4|.

Pedicles were formed and ligated with 0-Vicryl. The uterus with the ovaries and tubes were removed |4|.

The vagina was closed with interrupted sutures of 0-Vicryl. |4| We inspected the uterus. It appeared to me that perhaps 60% of the endometrial surface was involved with tumor. It appeared to me that there was no significant myometrial invasion, certainly less than 50% |5|.

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We then irrigated the abdomen with 2 liters of normal saline. The fasciawas closed with a running nonlocking suture of #1 PDS. We closed the subcutaneous tissues over rubber bumpers incorporating all of the subcutaneous tissue. We then closed the skin with surgical clips. The patient tolerated the procedure well and left the suite in good condition. _____________________________________________________________

|1| Diagnosis to report for the procedure performed. |2| Indication of what type of hysterectomy is being performed. |3| The type of surgical approach to perform the hysterectomy. |4| The steps taken to remove the uterus, ovaries and tubes. |5| This inspection is done for staging and grading the neoplasm. _____________________________________________________________ What are the CPT? and ICD-10-CM codes reported? CPT? Code: 58150 ICD-10-CM Code: C54.1 Rationales: CPT?: Total abdominal hysterectomy is performed. In the CPT? Index look for Hysterectomy/Abdominal/Total referring you to a range of codes. A total hysterectomy with bilateral salpingo-oophorectomy is the removal of the uterus, cervix, fallopian tubes (salpingo) and ovaries (oophor). Code 58150 is correct because the uterus with the ovaries and tubes are the only areas that were documented in being removed. Do not report 58180, supracervical hysterectomy, because there is no mention of the cervix being left. Code 58180 reports a subtotal hysterectomy and this was a total hysterectomy. Also "The vagina was closed with interrupted sutures of 0-Vicryl." The vagina would not be closed if the cervix was left in place. ICD-10-CM: In the Alphabetic Index look for Cancer (see also Neoplasm, by site, malignant). Go to the Table of Neoplasms and look for endometrium (gland) (stroma)/Malignant Primary column referring you to code C54.1. In the Tabular List there is no code for the stage the cancer is in, report code C54.1 for the diagnosis.

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