SURGICAL NOTE
PATIENT: JOHNSON, GOLDIE
AGE: 36
DATE: 01/15/2017
A 36-year-old woman with a history of multiple complicated ectopic pregnancies presented to the clinic for abdominal hysterectomy. Two days ago, an advanced interstitial uterine ectopic pregnancy was discovered and after careful consideration the patient elected to have a full hysterectomy. After the patient was prepped and anesthetized, the obstetrician performed a full incisional hysterectomy with removal of ectopic pregnancy, without removal of ovaries. Patient tolerated the procedure well and was sent to post-operational recovery.
How should the OB code for this surgical procedure?
Explanation
Answer: C - The OB should code for this surgical procedure with code 59135 (Surgical Treatment of Ectopic Pregnancy; Interstitial, Uterine Pregnancy Requiring Total Hysterectomy). Code 58150 is inappropriate because it is used for a total hysterectomy performed, for other reasons, not for an ectopic pregnancy. Code 59120 is also inappropriate because it is used for the removal of an ectopic pregnancy located on the fallopian tube or ovary, not in the uterus. Code 59136 codes for the removal of an interstitial uterine pregnancy, but it does not take into account the resection of the uterus.
