LOCATION: Inpatient, Hospital

LOCATION: Inpatient, Hospital

PATIENT: Margaret Hill

ATTENDING PHYSICIAN: Ronald Green, MD

SURGEON: Andy Martinez, MD

PREOPERATIVE DIAGNOSIS: Postmenopausal bleeding

POSTOPERATIVE DIAGNOSIS: Postmenopausal bleeding

PROCEDURE PERFORMED: Hysteroscopy with fractional dilatation and curettage

ANESTHESIA: General endotracheal

ESTIMATED BLOOD LOSS: Less than 25 cc

IRRIGATION: 400 cc used, 400 cc recovered

FLUIDS: 1,000 cc

FINDINGS: Uterus sounded to 4 inches and the cervix descends to the opening. The patient has a second-degree cystocele and a first-degree rectocele with gaping introitus.

PROCEDURE: The patient was prepped and draped in the lithotomy position under general endotracheal anesthesia, and the bladder was straight catheterized. A weighted speculum was placed in the vagina and the anterior lip of the cervix was grasped with a single-toothed tenaculum. The Kevorkian curet was then used to obtain endocervical curettings. The uterus was then sounded to a depth of 4 inches. The cervical os was then dilated to allow passage of the hysteroscope. The hysteroscope was then used to document intrauterine morphology. There was an endometrial polyp present. The cervical os was then serially dilated further to allow passage of a sharp curet. Stone polyp forceps were used to remove the endometrial polyp. The sharp curet was then used to sample the endometrial cavity, with scant return of tissue. The tenaculum was removed from the cervix. The tenaculum site was oversewn with 3-0 chromic figure-of-eight suture. The weighted speculum was removed from the vagina. All sponges and needles were accounted for at the completion of the procedure. The patient tolerated the procedure well, and when she left my care, she was doing well. The patient was then turned over to Dr. Sanchez for the gallbladder surgery.

PATHOLOGY REPORT LATER INDICATED: Benign endometrial polyp

One or more of the following codes are reported incorrectly for this case. Indicate the incorrect code or codes.

SERVICE CODE(S): Hysteroscopy, 58555; Dilation and curettage, 58120-51

CD-10-CM DX CODE(S): Postmenopausal bleeding, N95.0

INCORRECT/MISSING CODE(S): __________________________