The posterior vaginal cuff was made hemostatic with placement of a running lock suture with 0-Vicryl. The anterior and posterior cul-de-sac were entered without difficulty. Then, with the aid of the Bovie cautery, we proceeded to place an incision along the cervical uterine junction. We then proceeded to inject approximately 13 cc of low-dose Pitressin. The cervix was easily identified and was grasped with single-toothed tenaculum. After the exam under anesthesia, |2| a short-weighted speculum was placed in the vagina, and a Deaver retractor was used. ![]() An excisional biopsy |1| of the lesion was performed. The external genitalia were examined with findings as above. The patient was prepped and draped in the usual dorsal lithotomy position in the Yellowfin leg rests. Description of Procedure: The patient was taken to the operating room, where general anesthesia was found to be adequate. This site was biopsied and sent to pathology. There was also moderate erythema of the labia minora and introitus, with some white epithelial changes below the clitoris that appear consistent with possible lichen sclerosis. She also had a Grade I to II uterine prolapse. Findings at the Time of the Surgery: There was a Grade II to III cystocele. She has no stress urinary incontinence and is sexually active. She is taken to the operating room for definitive management of her prolapse and pelvic pain. What are the CPT® and ICD-10-CM codes reported?Ĭase 2 Preoperative Diagnosis (es) 1.Uterine prolapse 2.Cystocele 3.Pelvic pain Postoperative Diagnosis (es) 1.Uterine prolapse 2.Cystocele 3.Vulvar lesion Procedure Performed Total vaginal hysterectomy Anterior colporrhaphy Vulvar biopsy Indications for Procedure: Patient is a 65-year-old woman with uterine prolapse, specifically cystocele, which was associated with pelvic pain. |4| Closure is bundled into this procedure. Also, code for the excision of the verrucous lesion. |3| Although multiple modalities were used, the code can only be billed once for the VIN III lesions. |2| Multiple treatment modalities are covered with code 56501. |1| Although the findings are not enough to code from, they often give important details that can help a you follow the operative report. The patient was taken to the PACU in stable condition. The patient tolerated the procedure well, all sponge and needle counts were correct. |4| Silvadene cream was liberally applied to the area. The excision defect was closed with 3-0 Polysorb with interrupted stitches. Additional laser ablation was done of small acetowhite and hyper pigmented areas around the introitus and margins of the excision. The area with verrucous lesions (1 cm) was excised using a scalpel |3| and needle-tipped cautery. ![]() Laser ablation |2| of the vulvar lesion at 7 o'clock was performed. A sponge soaked in 3% acetic acid was placed over the vulva and perianal area for several minutes, and the findings were noted as above. Wet towels were used around the vulva and anus to drape and a wet sponge was placed in the vagina. ![]() She was prepared and draped in normal sterile fashion in dorsal lithotomy position in the candy cane stirrups. Procedure: Patient was taken to the operating room where general anesthesia was induced. A small acetowhite lesion was seen on the vulva approximately 1 cm to the right of the posterior fourchette. Thick acetowhite at 7 o'clock around introitus and a cluster of verrucous acetowhite lesions from 3-5 o'clock. Operative Findings: |1| After application of 3% acetic acid, acetowhite area is seen almost circumferentially around the vaginal opening. Patient refused in-office biopsy and opted for see-and-treat management with CO2 laser and excision. Now has discomfort and pain with sitting on the left side and on exam found to have painful verrucous lesion, similar in appearance to previous dysplasia. Case 1 Preop Dx: Recurrent VIN III Postop Dx: Recurrent VIN III Procedure: 1.CO2 laser ablation of vulvar dysplasia 2.Excision vulvar dysplasia Indications: 36-year-old female, heavy smoker, with long history of severe dysplasia of the vulva, cervix, and perianal area.
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