Question

What is the CPT code(s) for this case and if any modifier(s) if applicable?

of multiple miscarriages. 6. PREOPERATIVE DIAGNOSIS: Multiple miscarriages and hemorrhaging. POSTOPERATIVE DIAGNOSIS: Metrorrhagia. Acute salpingitis, bilaterally. History of multiple PROCEDURE: Dilation and curettage. Laparoscopic salpingectomy, bilateral. GROSS FINDINGS: Cervix dilated easily with dilator. The internal measurement of the uterii for. The internal measurement of the uterus was 3 inches, and no adnexal masses were noted. Moderate amount of endometrial tissue was present. Inspection of the abdomen revealed no injuries noted of the bowel or mesentery, and both tubes and ovaries annoma normal, as did the uterus. Liver edge was sharp, and no unusual masses were noted. After adequate anesthesia, the patient was placed in the lithotomy position; the vaginal area was prepped and draped in the usual manner. The cervix was grasped with a single-tooth tenaculum and dilated without difficulty. The endometrium was curettaged with a sharp curette, and the curette was removed. A uterine cannula was put in place. The abdomen was then prepped and draped in the usual manner, and a needle was placed through an infraumbilical incision in the pelvis. The abdomen was then insufflated with 3 liters of Co, and the needle removed. An 8-mm trocar was placed through an enlarged infraumbilical incision and a laparoscope put in place with findings as noted above. A 6-mm trocar was placed through the suprapubic incision in the pelvis and the abdomen then viewed. The right tube was identified, grasped 2 cm from the cornea, and electrically cauterized and a portion excised. The left tube was identified, grasped, and cauterized and a portion excised in a similar manner. The view was excellent. No injury was noted, and the gas was allowed to escape from the abdomen. All instruments were removed, and me infraumbilic incision was closed with an interrupted 00 subcutaneous chromic suture. The single tenaculum and uterine cannula were removed, and the patient was taken to the recovery room satisfactory condition.

Answer 1

Dilation and curettage(D&C) is a procedure in which material from the inside of the uterus is removed.THe dilation refers to dilation of the cervix,the lower part of the uterus that opens into the vagina.currettage refers to the scraping or removal of tissues lining the uterine cavity(endometrium) with asl surgical instrument called a curette.some curettes are sharp while others use suction.

REASONS FOR D&C

There are number of reasons a D&C might be performed.in some cases,the procedure is used to gain information abouy the uterus to diagnose a medical condition.in other cases,the procedure is used to treat a medical problem or condition.

CPT codes are current procedural terminology is a medical code that is used to report medical,surgical,and diagnostic procedures and services to entities such as physicians,health insurance companies and accreditation organizations.CPT codes are used in conjunction with ICD-9-CM or ICD-10-CM numerical diagnostic coding during electronic medical billing process

CPT CODES

salpingectomy,partial or total,unilateral or bilateral-58700

D&C(non obstetrical)-58120

Curettage postpartum-59160

Laproscopi,surgical removal of tubes and/or ovaries-58661

Laproscopic,surgical,removal of lesions/cysts of ovaries and pelvis-58662

Laproscopic treatment of Ectopic,w/salpingectomy and/or oophorectomy-59151.

So in this case the correct CPT codes are 58120(D&C) and 58661(laproscopic bilateral salpingectomy).there is a CPT assisted article from jan.2002 that stated code 58661 was unilateral procedure,so modifier -50 should be appended when the procedure is performed bilaterally.