Find comprehensive information on Tubo-Oophorectomy including clinical documentation requirements, medical coding guidelines, ICD-10 codes, postoperative care, and pathology reports. Learn about unilateral and bilateral Tubo-Oophorectomy procedures, surgical techniques, and potential complications. This resource provides valuable insights for healthcare professionals, medical coders, and patients seeking information on Tubo-Oophorectomy diagnosis, treatment, and recovery.
Also known as
Salpingo-oophorectomy
Surgical removal of fallopian tube(s) and ovary/ovaries.
Other diseases of fallopian tube and ovary
Encompasses other specified conditions affecting these organs.
Acquired absence of organs
May be used to indicate the absence of organs post-surgery.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is it unilateral or bilateral?
Unilateral
Which side? Right or Left?
Bilateral
Code O15.33 - Bilateral salpingo-oophorectomy
When to use each related code
| Description |
|---|
| Removal of fallopian tube and ovary |
| Salpingectomy only |
| Oophorectomy only |
Missing or incorrect laterality (right, left, bilateral) for the tubo-oophorectomy can lead to inaccurate coding and reimbursement.
Distinguishing between partial and total tubo-oophorectomy is crucial for proper code assignment and impacts clinical documentation integrity.
Lack of clear documentation supporting the medical necessity of the tubo-oophorectomy may trigger audit scrutiny and denial of claims.
Patient presented with (indicate presenting symptom, e.g., pelvic pain, abdominal distension, abnormal vaginal bleeding) prompting evaluation for possible gynecological pathology. Past medical history includes (list relevant medical history, e.g., endometriosis, ovarian cysts, ectopic pregnancy, pelvic inflammatory disease, infertility). Surgical history includes (list prior surgeries, especially gynecological or abdominal procedures). Family history is significant for (note family history of ovarian cancer, breast cancer, or other relevant genetic predispositions). Medications include (list current medications). Physical examination revealed (describe findings, e.g., abdominal tenderness, palpable mass, adnexal fullness). Pelvic ultrasound demonstrates (describe ultrasound findings, e.g., enlarged ovary, complex ovarian cyst, tubal thickening, free fluid). CA-125 level (report value if obtained). Preoperative diagnosis of (state preoperative diagnosis, e.g., ovarian cyst, tubo-ovarian abscess, ectopic pregnancy, suspected ovarian malignancy) was made. The patient was counseled regarding the risks and benefits of surgical intervention, including salpingo-oophorectomy, unilateral versus bilateral salpingectomy, oophorectomy, and the potential impact on fertility. Informed consent was obtained. A laparoscopic rightsidedleftsided (specify laterality) tubo-oophorectomy was performed. Intraoperative findings confirmed (describe intraoperative findings, e.g., hemorrhagic cyst, torsioned ovary, ruptured ectopic pregnancy, tubo-ovarian abscess). The procedure was uncomplicated, and hemostasis was achieved. The specimen was sent for pathological evaluation. Postoperative diagnosis: (state postoperative diagnosis based on pathology report, e.g., benign ovarian cyst, endometriosis, ectopic pregnancy, ovarian cancer). The patient tolerated the procedure well and was discharged in stable condition with postoperative instructions. Follow-up with gynecology is scheduled for (date). ICD-10 code (insert appropriate ICD-10 code) and CPT code (insert appropriate CPT code) for billing purposes.