How to Answer What Code Code Questions (Complete Guide)
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Original Question
What is the ICD 10 code and CPT code for the following: Preoperative Diagnosis: Uterine fibroids, excessive bleeding Postoperative Diagnosis: Submucosal fibroid Procedure: Laparoscopic Total abdominal hysterectomy with removal of bilateral tubes Anesthesia: General Anesthesia Procedure Details: The patient was identified and brought to the operating room. After proper positioning on the operating table, general anesthesia was administered, and the patient was placed in the dorsal lithotomy position. A Foley catheter was placed, and the abdomen was prepped and draped in a sterile fashion. A small infraumbilical incision was made, and a Veress needle was inserted for the creation of pneumoperitoneum. A 10mm trocar was then placed through the umbilicus under direct vision, and the abdominal cavity was insufflated. The abdomen was carefully explored, and the uterus was palpated. There were no signs of abnormal adhesions, and the structures were normal in appearance except for an enlarged uterus with fibroids. The round ligaments were identified bilaterally. Using LigaSure, the round ligaments were divided. The infundibulopelvic ligaments were identified, and the fallopian tubes were dissected free. Both fallopian tubes were then removed using laparoscopic scissors. The uterine arteries were carefully identified and cauterized. The uterine body was then transected, and the uterus was carefully mobilized. The specimen was removed via morcellation and bag method. After the uterus and tubes were removed, meticulous hemostasis was achieved. The peritoneum was inspected for any remaining bleeding points. The trocar sites were closed under direct visualization using absorbable sutures for fascial closure and dermal staples or adhesive for skin closure. There were no complications. Patient was taken to recovery. Pathology, gross: Uterus, morselized and bivalved, 281 g; bilateral fallopian tubes.
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