Wiki Exam under anesthesia, repair of vaginal abrasion

MaureenDL123

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Pt. had cerclage removal (without anesthesia), then moderate vaginal bleeding was encountered. A speculum exam was performed and the cervix was noted to be hemostatic, with no bleeding coming from the os. A small vaginal abrasion was suspected and thought to be the cause of bleeding, though could not be easily visualized due to laxity of vaginal tissue. A lap pad was placed into the vagina to apply pressure, with good effect. Reviewed plan to remove packing after a short period of time, and move to the OR for exam/repair if continued bleeding. The patient was taken to the operating room and given spinal anesthesia. A vaginal abrasion was visualized at the left anterior vaginal wall and was noted to be bleeding. The abrasion was reapproximated with 2-0 vicryl suture and excellent hemostasis was obtained. The rest of the vagina and cervix were examined and within normal limits. No bleeding from the cervix was visualized. How would you bill this? Thank you.
 
Cerclage was removed, transected sharply using scissors. The cervix was examined and noted to be 1cm dilated, no cervical defects were seen. Moderate vaginal bleeding was encountered. A speculum exam was performed and the cervix was noted to be hemostatic, with no bleeding coming from the os. A small vaginal abrasion was suspected and thought to be the cause of bleeding, though could not be easily visualized due to laxity of vaginal tissue. A lap pad was placed into the vagina to apply pressure, with good effect. Reviewed plan to remove packing after a short period of time, and move to the OR for exam/repair if continued bleeding.
Same MD did the repair.
 
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