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In: Nursing

LOCATION: Inpatient, Hospital PATIENT: Melissa Houtena ATTENDING PHYSICIAN: Andy Martinez, MD SURGEON: Andy Martinez, MD PREOPERATIVE...

LOCATION: Inpatient, Hospital

PATIENT: Melissa Houtena

ATTENDING PHYSICIAN: Andy Martinez, MD

SURGEON: Andy Martinez, MD

PREOPERATIVE DIAGNOSES 1. Three prior cesarean section deliveries. 2. Voluntary sterilization.

POSTOPERATIVE DIAGNOSIS: Same as Preoperative.

PROCEDURES PERFORMED 1. Repeat lower segment transverse cesarean section. 2. Bilateral Pomeroy tubal ligation.

ANESTHESIA: General.

PREAMBLE: The patient is a 30-year-old woman, gravida 4, para 3, at 36 weeks and 2 days gestation who presented initially to her hometown obstetrician in spontaneous labor. Because of her previous cesarean sections, she was transferred here. She was scheduled to have a repeat cesarean section. She also has expressed a desire for permanent sterilization and has signed the papers for a tubal ligation. She was sure of her decision to proceed with the tubal ligation. When she presented she was contracting every 2 minutes with moderate intensity. The cervix was not yet dilating, but with the intensity of contractions a decision was made to proceed with cesarean section for delivery.

PROCEDURE NOTE: The patient was taken to the operating room and a spinal anesthetic was administered. The patient was then prepped and draped in the usual manner in supine position with left lateral tilt. A Foley catheter was placed. A Pfannenstiel skin incision was made superior to the pre-existing scar. The fascia was then transversely incised. Peritoneal cavity was then carefully entered as the bladder was pulled up quite high anteriorly. The bladder was then taken away from the front of the uterus and reflected out of the way using the bladder retractor. A transverse incision was then made in the lower uterine segment, and there was delivery of a liveborn male infant with Apgar of 8 at 1 minute and 10 at 5 minutes and weight of 5 lb 8 oz. The baby was suctioned on the table and immediately handed to the neonatal intensive care team. The placenta was then manually removed and appeared to be intact. At this point the uterus was exteriorized to allow for better visualization. The uterine incision was closed in a single running locked layer of 0 Chromic. Good hemostasis was achieved. At this point attention was directed toward the fallopian tube. Both ovaries and fallopian tubes were identified and appeared to be completely normal. Fallopian tubes were grasped using Babcock clamps, and bilateral Pomeroy tubal ligation was carried out by tying off a loop of tube with plain suture and then excising the intervening portion of fallopian tube bilaterally. Good hemostasis of the fallopian tubes was ensured. At this point the uterus was replaced within the peritoneal cavity. Pericolonic gutters were swabbed free of blood and clots. The uterine incision was once again inspected and confirmed to be hemostatic. The fascia was then closed using running 0 Vicryl. Finally, skin was reapproximated using 4–0 Vicryl in a subcuticular manner. The patient tolerated this procedure well and went to the recovery room in good condition. There were no complications. The estimated blood loss was 300 cc. The patient received Ancef 1 gram IV after cord clamping.

Dr. Martinez will provide only the delivery service and tubal ligation. The patient’s hometown physician provided the antepartum care and will also provide the postpartum care.

Abstracting Questions:

1. Is the tubal ligation reported separately?

2. Is the history of previous C-section reported?

3. Is a Z code required for the tubal ligation?

4. What CPT code(s) would be reported for this case?

5. What ICD-10-CM code(s) would be reported for this case?

Expert Solution

1. Yes, the tubal ligation was reported separately,as the lady has expressed the desire for permanent sterilization and had signed the papers for tubal ligation.

After the delivery of baby ,suturing of uterine incision was done and the ovary and fallopian tube were assessed and grasped using Babcock clamps and bilateral pomeroy tubal ligation was done by tying off the loop of tube with plain suture and excising the intervening portion of fallopian tube bilaterally.

2. Yes, history about three Cesarean section delivery were reported before the procedure .

3. Yes ,a Z code is a special group of codes provided in ICD -10-CM for the reporting of factors influencing health status and contact with health services. Z code for this case is Z98.51

4. CPT codes for this case is 58611- ligation of fallopian tubes done at the time of Cesarean section or intra abdominal surgery.

5. The ICD-10-CM code for tubal ligation is Z98.51 and for elective cesarean section is 082.0

Nightingale answered 2 years ago

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