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Exam 21: Reproductive, Intersex Surgery, Female Genital System, and Maternity Care and Delivery

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Question 1

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Total abdominal hysterectomy with an anterior/posterior colporrhaphy and an enterocele repair. CPT Codes: ____________________

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58150, 57265-51

Question 2

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Drainage of left ovarian cyst, abdominal approach. CPT Code: ____________________

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Question 3

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Colposcopy of the vulva with six biopsies. CPT Code: ____________________

Location: Inpatient Hospital OPERATIVE REPORT PRE/POSTOPERATIVE DIAGNOSIS: Postmenopausal bleeding with probable polyp seen on saline sonohysterogram. OPERATIVE FINDINGS: Endometrial polyp seen arising from the left cornual region.Otherwise, benign uterine cavity. PROCEDURE: The patient was taken to the operating room and a general anesthetic was administered.The patient was then prepped and draped in the usual manner in lithotomy position and the bladder was emptied with a straight catheter. A weighted speculum was placed to allow for visualization of the cervix, which was grasped anteriorly using single toothed tenaculum.The uterus was then sounded to 9 cm in depth.The cervix was dilated to allow for insertion of the diagnostic hysteroscope.The uterine cavity was then inspected.Immediately apparent was a polyp arising from the left cornual region.Remainder of uterine cavity was inspected and appeared to be benign.Minimal endometrial tissue was otherwise present. At this point, the hysteroscope was removed and polyp forceps were placed within the uterus.Attempt was made to grasp the polyp but this could not be grabbed with the polyp forceps.Therefore, a sharp curet was used and the polyp was thereby obtained and removed.A small amount of endometrial tissue was also obtained by curettage.Once this had been completed, the hysteroscope was reinserted and the cavity was re-inspected.It was confirmed that the polyp was removed.Otherwise, the endometrial canal then appeared normal.At this point, the procedure was terminated.Tenaculum was removed and good hemostasis was ensured at the cervix.The patient tolerated this procedure well. There were no complications.Fluid in was 325 cc and was equal to fluid out at the end of the procedure.Estimated blood loss was minimal. CPT Code: ____________________

Intrauterine cordocentesis.Do not code the radiological portion of the procedure. CPT Code: ____________________

Amniocentesis.Code only the procedure, not the radiological service. CPT Code: ____________________

Total prenatal care for vaginal delivery after a previous cesarean delivery and postpartum services. CPT Code: ____________________

Colposcopy of the vulva with biopsy. CPT Code: ____________________

Dilation and curettage of cervical stump. CPT Code: ____________________

Colposcopy of the cervix with a biopsy. CPT Code: ____________________

This term describes an incision of the vagina to gain access to the peritoneal cul-de-sac to explore or to drain an abscess.

Colpocentesis. CPT Code: ____________________

Code the vaginal removal of a 230-gram uterus. CPT Code: ____________________

The code 59400 doesn't include:

Incision and drainage of these glands are not reported using Female Genital System codes but are instead reported using Surgery section, Urinary System codes.

The code for a curettage performed after delivery is 58120.

Antepartum care only after vaginal delivery by another physician, eight visits. CPT Code: ____________________

Removal of cerclage sutures under general anesthesia. CPT Code: ____________________

According to the text, vulvectomy codes are divided based on the ____ and extent of vulvar area removed during the procedure.

The physician performs a surgical laparoscopy with fimbrioplasty. CPT Code: ____________________