ICD-10-PCS CODE! It will have 7 characters!!! Such as 00QTXZZ 6. Operative Report PREOPERATIVE DIAGNOSIS: Postmenopausal bleeding

ICD-10-PCS CODE!

It will have 7 characters!!!

Such as 00QTXZZ

Transcribed Image Text:

6. Operative Report PREOPERATIVE DIAGNOSIS: Postmenopausal bleeding POSTOPERATIVE DIAGNOSIS: Postmenopausal bleeding plus uterine polyps PROCEDURE PERFORMED: Hysteroscopy, polypectomy and D/C SPECIMENS REMOVED: Endometrium and polyps sent to pathology multiple FINDINGS: Small uterus, difficult to assess on bimanual exam secondary to body habitus. Anteverted m large polyps in the uterine cavity on hysteroscopy. Atrophic external genitalia and vagina. INDICATIONS: The patient is a postmenopausal woman with postmenopausal bleeding, who presents for sur- gical management and diagnosis. Risks, benefits, and alternatives of procedure was explained. All consents were signed. DESCRIPTION OF PROCEDURE: Under general anesthesia, the patient was positioned in the dorsal lithotomy position and prepped and draped in standard sterile fashion. A weighted speculum was then inserted into the patient's vagina but was found not to reach the posterior fornix so wide-angle retractors were used anteriorly and posteriorly to visualize the cervix. The cervix was visualized. A single-tooth tenaculum was used to grasp the anterior lip of the cervix. The wide-angle retractors were then used for retraction for further visualization of the cervix. Cervix was dilated to a 7-French with sequential dilation, and the hysteroscope was prepared in stan- dard fashion. The hysteroscope was then inserted into the patient's cervical os and advanced into the uterine cavity. Upon entry into the uterine cavity, several pedunculated polyps were noted. The decision was made to then proceed with polypectomy. The snare was advanced through the hysteroscope and polyps were resected in standard fashion. Tubal ostia were visualized and found to be normal and the hysteroscope was then removed. The decision was made to proceed dilation and curettage. A small, sharp curette was advanced to the patient's cervical os and sharp curettage in a 360-degree fash- ion was performed until adequate specimen was obtained and a gritty texture was noted throughout. At this time, the specimen was sent to pathology labeled endometrial curetting along with the polyp specimens obtained. The procedure was then discontinued. All instruments removed from patient's vagina. On inspec- tion, the tenaculum sites were found to be hemostatic. The patient's vagina was swept with a clean sponge to clear of any remaining blood clots and debris. The patient was repositioned into supine position, and awoken from anesthesia. 6. Operative Report PREOPERATIVE DIAGNOSIS: Postmenopausal bleeding POSTOPERATIVE DIAGNOSIS: Postmenopausal bleeding plus uterine polyps PROCEDURE PERFORMED: Hysteroscopy, polypectomy and D/C SPECIMENS REMOVED: Endometrium and polyps sent to pathology multiple FINDINGS: Small uterus, difficult to assess on bimanual exam secondary to body habitus. Anteverted m large polyps in the uterine cavity on hysteroscopy. Atrophic external genitalia and vagina. INDICATIONS: The patient is a postmenopausal woman with postmenopausal bleeding, who presents for sur- gical management and diagnosis. Risks, benefits, and alternatives of procedure was explained. All consents were signed. DESCRIPTION OF PROCEDURE: Under general anesthesia, the patient was positioned in the dorsal lithotomy position and prepped and draped in standard sterile fashion. A weighted speculum was then inserted into the patient's vagina but was found not to reach the posterior fornix so wide-angle retractors were used anteriorly and posteriorly to visualize the cervix. The cervix was visualized. A single-tooth tenaculum was used to grasp the anterior lip of the cervix. The wide-angle retractors were then used for retraction for further visualization of the cervix. Cervix was dilated to a 7-French with sequential dilation, and the hysteroscope was prepared in stan- dard fashion. The hysteroscope was then inserted into the patient's cervical os and advanced into the uterine cavity. Upon entry into the uterine cavity, several pedunculated polyps were noted. The decision was made to then proceed with polypectomy. The snare was advanced through the hysteroscope and polyps were resected in standard fashion. Tubal ostia were visualized and found to be normal and the hysteroscope was then removed. The decision was made to proceed dilation and curettage. A small, sharp curette was advanced to the patient's cervical os and sharp curettage in a 360-degree fash- ion was performed until adequate specimen was obtained and a gritty texture was noted throughout. At this time, the specimen was sent to pathology labeled endometrial curetting along with the polyp specimens obtained. The procedure was then discontinued. All instruments removed from patient's vagina. On inspec- tion, the tenaculum sites were found to be hemostatic. The patient's vagina was swept with a clean sponge to clear of any remaining blood clots and debris. The patient was repositioned into supine position, and awoken from anesthesia.

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The ICD10PCS codes for this procedure would be 0SZ0ZZ Extirpation of uterus polyps 0SZ3ZZ Extirpa... View the full answer