Sample coded report for Ovary cystectomy CPT code

Pre-op Diagnosis: Bilateral ovarian cysts [N83.201, N83.202]

Post-op Diagnosis: Same as Pre-op s/p procedure performed

Procedure(s): OVARIAN CYSTECTOMY ROBOTIC ASSISTED/ ROBOTIC ASSISTED UNILATERAL OVARIAN CYSTECTOMY, POSSIBLE UNILATERAL SALPINGOOOPHORECTOMY

SALPINGOOPHORECTOMY BILATERAL ROBOTIC ASSISTED/ POSSIBLE UNILATERAL

Anesthesia: General

Complications: none

Findings:

Normal appearing female external genitalia
On laparoscopic entry, uterus and right ovary normal appearing. Left ovary with an approximately 3 cm hardened cyst on the superior portion. Tiny paratubal cysts bilaterally.
Hemostasis noted at the end of case.

Sample Coded report for Rotator Cuff repair CPT code

Technique:

The patient was taken to the operating room. After adequate anesthesia, the patient was placed in dorsal lithotomy position, prepared and draped in the routine sterile fashion. Ancef and Flagyl were given preoperatively for prophylaxis. A timeout was performed. A Foley catheter was then inserted.

0.25% Marcaine was used prior to incision at all port sites. An 8 mm vertical incision was made immediately left of midline in the upper abdomen at approximately 25 cm above the pubic symphysis. A Veress needle was then inserted. The saline drop test was used to confirm Veress needle placement. The gas was connected with initial opening pressure of less than 8 mmHg. The abdomen was then insufflated to 15 mmHg. The Veress needle was then removed and the robotic trocar was inserted. The robotic camera was then inserted and the insertion site was inspected. Three additional 8 mm horizontal incisions were made for robotic trocar sites, approximately 8 cm apart from each other, 2 in the left upper abdomen and 1 in the right upper abdomen. Between the right lateral robotic trocar and the midline trocar site, an 10 mm horizontal incision was made for the assist port site, for a total of 5 laparoscopic trocar sites. All trocars were inserted under direct visualization. The da Vinci robot was then docked with the camera in arm 3, monopolar scissors in arm 4, ProGrasp in arm 1 and fenestrated bipolar in arm 2. The abdomen and pelvis were surveyed with the findings as noted above.

Using laparoscopic scissors, the paratubal cysts were excision and removed using graspers from the assist port site, each being collected for pathology. Attention was then placed on the approximately 2-3 cm right ovarian cyst, which was carefully peeled away and excised from the remaining normal-appearing ovarian tissue, making sure to ensure hemostasis throughout the process.

An endocatch bag was inserted through the assist port, the specimen was added to the bag carefully to prevent spillage of contents. The bag was brought to the abdominal cavity and the specimen was removed and sent for pathology. Next, the pelvis was inspected and hemostasis was noted. The abdominal pressure was lowered to 6 mmHg and continued hemostasis was noted. The neo close was used to close the 10 mm assist port. All instruments were then removed from the abdomen. The da Vinci robot was then undocked and the abdomen was exsufflated and all trocars were then removed.

The skin at all port sites were then closed with 4-0 Monocryl and Dermabond was used as a skin adhesive. The Foley catheter was removed.

At the end of the procedure, all sponge, instrument, and needle counts were correct x2. The patient tolerated the procedure well, and was awoken from anesthesia, extubated and returned to recovery room in stable condition.

58662 LAPS FULG/EXC OVARY VISCERA/PERITONEAL SURFACE; (-LT Left side of body)

58661 LAPAROSCOPY W/RMVL ADNEXAL STRUCTURES

N83.201 – Unspecified ovarian cyst, right side

N83.202 – Unspecified ovarian cyst, left side