Ob-Gyn Coding Alert

Editors Note: Experts in ob/gyn coding agree that successful coding in this specialty requires a sound knowledge of medical terminology, the procedures involved and correct codes and coding. Our goal is to present actual coding cases within the context of the medical terminology and procedures. If you have a case youd like to submit for consideration, please send it via fax, email or mail (contact information on page 2.)

A 65-year-old woman presents to her gynecologist with the complaint that everything is falling out. Twenty years ago, the woman had a vaginal hysterectomy and has been problem-free until the emergence of the current problem. Upon examination, the woman is found to have a total prolapse of the vaginal wall and vaginal cuff in clear view at the introitus. Upon further examination, a cystourethrocele and high rectocele are also noted. After discussing the findings with the patient, the ob/gyn schedules surgery to perform a sacrospinous ligament fixation, enterocele repair and anterior and posterior repair. Following the surgery, the coder receives an operative report that describes an anterior/posterior (A&P) repair with enterocele repair along with a sacrospinous ligament fixation.

Terminology and Procedures

A womans reproductive organs are suspended from the pelvic bones by an elaborate structure of muscles, ligaments and connective tissue. With age, the stress of bearing children, previous surgery and other factors, the suspension system weakens. The result is a loss of pelvic support, sometimes called pelvic relaxation. The patient will often present with a feeling of heaviness or fullness in the pelvic region. She may describe her symptoms as something falling out of the vagina. She also may experience incontinence or urine leakage, difficult bowel movements and lower back and abdominal pain.

If the pelvic support continues to weaken, as in this case, one or more of the surrounding organs (bladder, small intestine, rectum or uterus) may protrude or bulge into the vagina. This condition is referred to as vaginal or genital prolapse (ICD-9 codes 618.X). The selection of the fourth digit will depend on which organs or combination of organs are protruding into the vagina. When reviewing these operative reports, the following definitions will be helpful.

Cystourethrocele simultaneous occurrence of a cystocele and urethrocele

Cystocele descent of a portion of the posterior bladder wall and trigone (the small triangular space at the base of the bladder) into the vagina.

Urethrocele sagging of the urethra

Rectocele rectovaginal hernia in which the rectum prolapses into the vaginal canal

High rectocele rectocele that involves the entire posterior vaginal wall

Enterocele herniation of the rectouterine pouch into the rectovaginal septum, which presents as a bulging mass in the posterior fornix and upper posterior vaginal wall

Note: Vaginal vault prolapse following a hysterectomy is the result of [...]