Provide the CPT and ICD-9 diagnosis codes for the following inpatient hospital scenario.
PRE/POSTOPERATIVE DIAGNOSIS: Postmenopausal bleeding with probable polyp
Seen on saline ...
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
At this point, the hysteroscope was removed, and polyp forceps was 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 reinspected. 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.
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