Yes - this is not the op note. I will say the "Operative findings: large left adnexal cystic mass involving fallopian tube" hints that both codes are not appropriate here. Likely the surgeon was performing the cystectomy and the left salpingectomy was simply part of removing the cyst. But the full description should always be reviewed when coding surgery.
The physician was able to upload the detailed op note with procedure details.
DESCRIPTION OF PROCEDURE: The patient was brought back to the operating room
and placed on the operating table in supine position. The patient was then
placed under general anesthesia by the anesthesiologist. Next, the patient was
placed in the Allen stirrups for dorsal lithotomy position. The patient's
vagina, perineum and abdomen were sterilely prepped. The patient was then
sterilely draped. The patient's bladder was emptied prior to beginning the
procedure. A sponge on a ring forceps was placed in the vagina in the posterior
fornix to use for manipulation if needed. A red rubber catheter was placed in
the bladder through the urethra and left in place throughout the procedure. A
timeout was performed. The patient was sterilely draped. The scalpel was used
to make an infraumbilical incision and through this incision placed an 8-mm
trocar and laparoscope under direct visualization, abdominal placement was
verified. The patient was placed in Trendelenburg position. Upon examination
of the pelvis, a large left adnexal cystic mass was noted involving coming off
the left fallopian tube. The left ovary was noted to be underneath the mass and
noted to be grossly normal. The right fallopian tube and ovary were noted to be
grossly normal. Two additional ports were made in the right and left lower
quadrant by making an incision with the scalpel and placing 5 mm trocar sleeve
through these incisions under direct visualization. These ports were used for
graspers. The LigaSure device was placed in 1 port and a grasper placed in
another port and the specimen was removed using the LigaSure device with
successful clamping, ligating and cutting the left fallopian tube which
contained the mass. After freeing the specimen, the infraumbilical 8 mm trocar
was switched for an 11 mm trocar in order to place the specimen bag through.
Once the specimen bag was placed, the specimen was then placed in the specimen
bag. The specimen was too big to fit through the infraumbilical incision.
Therefore, the specimen while in the bag was drained of approximately 100 mL of
amber fluid, which will be sent to pathology. Once the specimen was reduced in
size the specimen bag was then removed through the infraumbilical incision
without any difficulty. The pelvis was then reinspected using laparoscope and
the coagulated areas were noted to be hemostatic. There was no bleeding from
the operative site. The trocar sleeves were removed and the CO2 gas was removed
from the pelvis and the abdomen. The infraumbilical incision was first closed
in the fascia using 2-0 Vicryl suture with a figure-of-eight stitch and then
closing the skin with a 3-0 Monocryl with subcuticular stitch covered by
Dermabond. The right and left lower abdominal incisions were closed using 3-0
Monocryl to close the skin. Then, covered with Dermabond. The instruments were
removed. Sponge stick was removed from the vagina intact and the catheter
removed from the bladder, approximately 30 mL of urine was noted that had been
collected. The patient was taken out of dorsal lithotomy position, placed
supine on the operating table. The patient was extubated in the operating room
by the anesthesiologist without any difficulty and transferred from the
operating room table to the stretcher and brought to recovery room in stable
condition.
I am reviewing this op note and i wanted to confirm if 58661 and 58662 can be billed together in this instance. Any input is appreciated. Thank you. 