Ob-Gyn Coding Alert

"Editors Note: Correctly coding surgical procedures that can pass any audit and also provide maximum reimbursement often turns on the subtle communication between physician and coder through the surgical report. Our goal in these case presentations is to assist coders and ob/gyn practices to excel in understanding the intricacies of ob/gyn coding by examining real coding situations. If you have a case youd like to submit for consideration, please send it to the Editor of OCA via fax, email or mail.

A 42-year-old woman presents to her gynecologist complaining of vaginal pain. The patient is gravid 2, para 2, and eight years ago she experienced a vaginal vault prolapse that was successfully repaired with a suspension procedure that used a Gore-Tex graft. The patient has been in good health except for the recent onset of vaginal pain. Following the gathering of a detailed history, an office examination shows a dimple in the area of the vaginal apex with some vaginal granulation tissue in the area. Because the area is extremely painful and visualization poor, the physician and patient make the decision to proceed to surgery to perform an exam under anesthesia. Depending on what the physician finds, the surgery may also include the removal of the graft or some other more conservative approach. The preoperative diagnosis is vaginal granulation tissue secondary to foreign body.

The patient is taken to surgery and examined under general anesthesia. She is found to have a vaginal defect or fistula located in the vaginal apex. Using cautery, the physician excises the granulated tissue around the fistula and then closes the fistula with sutures.

Terminology and Procedures

The history of this patient explains that she has been pregnant (gravid) twice and delivered (para) 2 viable infants (weighing more than 500 grams). It also explains that she has had a vaginal vault prolapse, which is a weakening of the support of the vagina due to the stress of bearing children, age or previous surgeries. The prolapse allows for the protrusion of one or more surrounding organs (see full description of cystocele, cystourethrocele, urethrocele, rectocele, and enterocele in January 1999 Ob-Gyn Coding Alert, page 7). The old repair of this patients vaginal vault prolapse included a suspension procedure that included the placement of a synthetic graft made from a product called Gore-Tex. The placement of this graft requires an incision into the vaginal wall, which is closed around the graft to maintain the integrity of the vagina. Occasionally, granulation tissue (rough or grain-like tissue) forms around the graft site and may indicate a problem.

The surgical examination involved a careful look at [...]