ICD 10 Coding Alert

Reader Question:

Documentation Matters for Vaginal Cuff With Hematoma Evacuation

Question: My physician documented: "Open of the vaginal cuff with evacuation of the hematoma and re-suturing of the vaginal cuff." Should I use 57022 or 57023 for this? The patient is not postpartum (57022) but she is having this done 2 weeks after having a trachelectomy (removal of cervix), so would this be considered a trauma? She opened the vaginal cuff to suction the vaginal hematoma, and then resutured it. So would it then be 57023, since she did do it to remove the vaginal hematoma? I'm leaning more towards 57023 with modifier 78 (return to or) just because it's not postpartum. But I don't think it's necessarily "post-trauma." Am I correct?Virginia SubscriberAnswer: No. You should use the unlisted procedure 58999-78 (Unlisted procedure, female genital system [nonobstetrical]; Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during [...]
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