Hospital Outpatient Surgery Services Preoperative Diagnosis: Menorrhagia

The following documentation is from the health record of a 47—year-old female. Hospital Outpatient Surgery Services Preoperative Diagnosis: Menorrhagia. failure of conservative treatment Postoperative Diagnosis: Same Procedure: Hysteroscopy with biopsy. dilatation and curettage Diagnosis: Menorrhagia Anesthesia: General indications: The patient is a 4?-year—old multigravida female with increasing irregular vaginal bleeding. The uterus is very tender. and ultrasound reveals no specific adnexal masses. A Pap smear shows some chronic inflammatory cells and cervicitis. Bleeding has not been controlled in the past month with conservative therapy: thus. the patient is admitted for dilatation and curettage. and a hysteroscopy and biopsy will be carried out. Technique: Under general anesthesia. the patient was prepped and draped in the usual manner with Betadine. with her cervix retracted outward. Moderate cervical erosions were noted. The vaginal vault appeared to be clear. as did both adnexa. However. the uterus was thought to be slightly enlarged. Sound was passed into the intrauterine cavity after the cervix was found to be 3 cm deep. The cervix was dilated with Hegar dilators up to #5. The 5-mm Wolff scope. with normal saline irrigation. was then inserted. An inspection of the endocervical canal showed no abnormalities. Upon entering the uterine cavity, some irregular shedding of the endometrium was noted. Endometrial shedding was noted more to be the patient’s left cornu area than the right. The contour of the cavity appeared to be normal; no bulging masses or septation were noted. The Wolff scope was removed. and the cervix was further dilated with Hagar dilators up to #12. A medium-sharp curette was inserted into the uterine cavity and the uterus was curettaged in a clockwise manner. with a moderate amount of what appeared to be irregular proliferative endometrium being obtained. Again, the contour of the cavity appeared to be normal. Endometrial biopsies also were taken. The patient was transferred to the recovery room in good condition. Pathology report reveals secretory proliferative endometrium without additional abnormalities noted. Which of the following ICD—’lo-CM and CPT code sets will be reported? N920, N72, 58558 N920. 58558 N921]. N72. 58100. 58120 N72. N920. 58558 sees

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