The doctor performed a robotic hysterectomy, bilateral salpingectomy, and right ovarian cystectomy on the patient, Alice Simmons

QUESTION

Patient: Alice Simmons

Preoperative Diagnosis: Symptomatic uterine fibroids

Postoperative Diagnosis: Symptomatic uterine fibroids

Procedure: Robotic hysterectomy, bilateral salpingectomy, right ovarian cystectomy

Findings: Enlarged fibroid uterus weighing 224g; right ovarian cyst and endometriotic implants in the posterior pelvis near the bladder.

Estimated Blood Loss: less than 100 mL

Complications: None; patient tolerated the procedure well

Procedure in Detail: The patient was seen in the Holding Room. The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The patient was taken to the operating room,  and the procedure was verified as a robotic hysterectomy with bilateral salpingectomy. A tie out was held, and the above information was confirmed.

After induction of anesthesia, the patient was placed in lithotomy position and prepped and draped in the usual sterile manner. Foley catheter was placed. A v-care uterine manipulator was introduced into the endometrial cavity and secured.

An incision was made above the umbilicus and a 5-mm port introduced. Confirmation of abdominal placement was made with laparoscope. Two additional 8-mm ports were placed in the right and left lower abdomen under direct visualization. The midline was extended for a 12-mm port and a 5-mm port introduced in the nipple line on the left, just below the ribs.

The robot was docked and attention turned to the console.

The uterus was found to be enlarged with multiple fibroids and the ovaries were normal with a hemorrhagic cyst on the right ovary. The ureters were identified and noted to be away from the surgical field. The fallopian tubes were identified, grasped, and followed to the fimbriated ends.

They were dissected from their surrounding tissue with harp dissection and cautery. the cyst on the right ovary was dissected from the ovary and removed. The round ligaments were identified, cauterized with bipolar cautery, and cut. The anterior peritoneal reflection was incised and the bladder was dissected off the lower uterine segment. Hemostasis was observed. The uterine vessels were skeletonized, then clamped, and cauterized. Using the v-care as a guide, a posterior colpotomy was made. A circumferential incision was made around the cervix, and the uterus, cervix and tubes were delivered through the vagina. Vaginal cuff angles as well as the remainder of the vaginal cuff were closed using a v-lock suture, incorporating the utero-sacral ligaments for support. Lavage was carried out until clear. Hemostasis was observed.

Interceed was placed in the pelvis due to endometriosis being noted. The robot was undocked, and all instruments removed from the abdomen and the vagina. The midline fascial incision was closed with 0-vicryl suture and all skin incisions were closed with 4-0 vicryl.

A perineal laceration was noted due to the irregular shape of the uterus. This laceration was repaired with 3-0 vicryl suture.

Instrument, sponge, and needle counts were correct prior to abdominal  closure and at the conclusion of the case.

Signed: Dr. Jordana Morgan, MD

Use the following steps to select the appropriate codes for the case study.  Assign the ICD-10-PCS codes for the procedures.

1. Read through the case study and answer the question: What did the doctor do?  Identify the name of the procedures performed.

2. Now that you have identified the procedure, locate the code for the procedure in the ICD-10-PCS code book.

a. Search the Index for the procedure and search through the options for each procedure.

i.

ii.

iii.

3. Now that the procedure codes have been identified, review the case study and answer the following question: Why did the doctor do it? Identify the patient’s diagnoses.

4. Now that you have identified the patient’s diagnoses, search the ID-10-CM cod book for the correct code for this condition.

a. Search the Main Index for the name of the condition and search through any applicable sub terms and cross-references to locate the appropriate code.

i.

ii.

iii.

b. Verify the codes in the Tabular List. Locate the code identified previously in the Tabular Listing of codes and refer to any applicable guidelines, notes, and symbols. Does the code selected correctly identify the patient’s condition? If yes, list the code here:

i.

ii.

iii.

c. Check the procedure note and ICD-10-CM guidelines and conventions to determine the correct sequencing of the diagnosis codes, if applicable. Correctly sequence the diagnosis codes.

ANSWER

The doctor performed a robotic hysterectomy, bilateral salpingectomy, and right ovarian cystectomy on the patient, Alice Simmons. The procedures involved removing the uterus, fallopian tubes, and an ovarian cyst while using robotic assistance.

In the ICD-10-PCS code book

Robotic Hysterectomy
Search Index: “Hysterectomy, robotic”
Option: “0UTG3DZ – Excision of Uterus, Open Approach, Robotic Assistance”

Bilateral Salpingectomy
Search Index: “Salpingectomy, bilateral”
Option: “0UBC8ZX – Excision of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic”

Right Ovarian Cystectomy
Search Index: “Cystectomy, ovary, right”
Option: “0UDB8ZX – Excision of Right Ovary, Via Natural or Artificial Opening Endoscopic”

Patient’s Diagnoses

The patient’s diagnoses include “Symptomatic uterine fibroids” and “Right ovarian cyst.”

In the ICD-10-CM code book

Symptomatic Uterine Fibroids
Search Main Index: “Fibroids, symptomatic”
Option: “D25.9 – Leiomyoma of uterus, unspecified”

Right Ovarian Cyst
Search Main Index: “Cyst, ovary, right”
Option: “N83.20 – Unspecified ovarian cyst, right side”

Sequencing of Diagnosis Codes

According to ICD-10-CM guidelines and conventions, the correct sequencing of diagnosis codes should be based on the reason for the encounter. Since the procedures were performed to address both symptomatic uterine fibroids and the right ovarian cyst, the sequencing could be determined by the primary reason for the encounter. If the primary reason was the uterine fibroids, the code for “Leiomyoma of uterus” (D25.9) would be sequenced first, followed by the code for the right ovarian cyst (N83.20).

To recap:
Robotic Hysterectomy: 0UTG3DZ
Bilateral Salpingectomy: 0UBC8ZX
Right Ovarian Cystectomy: 0UDB8ZX

Diagnoses:
Symptomatic Uterine Fibroids: D25.9
Right Ovarian Cyst: N83.20

The sequencing of diagnosis codes could depend on the primary reason for the encounter, as guided by ICD-10-CM conventions and guidelines.