Ob-Gyn Coding Alert

Here’s the modifier you’ll need for a repair during previous surgery’s global period.

What’s key about coding vaginal cuff repair claims isn’t found in your CPT^® code book; what’s key is looking at your ob-gyn’s documentation and asking yourself, why did the ob-gyn need to perform the repair? Was it due to an injury or a previous surgery?

With that knowledge in hand, you can better examine all the possibilities and decide the appropriate code (and possibly modifiers) to apply to your claim. These three frequently asked questions will help you examine all your options.

Q1: How Do I Decvide What Repair Code to Use?

The first thing you should do when the ob-gyn performs a vaginal cuff repair is examine the operative report to determine why the patient required the repair.

Rationale: Your code might depend on whether the patient had an injury versus a surgical wound in that area, experts explain. For example, was it due to loosening or disruption of sutures from a previous surgery, or was it a repair of an injury to the vagina? Answering these questions will pinpoint the correct code to use. Follow the next two FAQs for code examples.

Q2: If Repair Dealt With Loose Sutures, What Should I Do?

You read your op notes and discovered the vaginal cuff repair dealt with loose sutures. Suppose the patient, who underwent a total abdominal hysterectomy (58150, Total abdominal hysterectomy [corpus and cervix], with or without removal of tube[s], with or without removal of ovary[s]), needs to return to the operating room for a vaginal cuff repair because the original sutures became loose, and a simple re-closure is documented.

In this case, you should report 58999 (Unlisted procedure, female genital system [nonobstetrical]). You would also need to submit your op report along with a cover letter that explains in simple, straightforward language exactly what your ob-gyn did, says Melanie Witt, RN, MA, an ob-gyn coding expert based in Guadalupita, New Mexico.

Remember to explicitly reference the nearest equivalent listed procedure in your explanatory note. For example, you might consider comparing the work to 12020 (Treatment of superficial wound dehiscence; simple closure), which has 5.52 relative value units (RVUs) in the facility setting.

Alternatively, if your physician has documented the repair’s size, use 12011-12018 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes ...), which range in RVUs from 1.63 to 5.12, as a comparison.

Be sure to append modifier 78 (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 the postoperative period) if the surgeon performs the repair during the previous surgery’s global period.

The diagnosis code for this repair will be T81.31XA (Disruption of external operation [surgical] wound, not elsewhere classified, initial encounter), Witt says. Note that while you may also find a code for the disruption of an internal surgical wound (T81.32XA, Disruption of internal operation (surgical) wound, not elsewhere classified, initial encounter), this code would be incorrect to report since the disruption is taking place outside of the peritoneal cavity.

Q3: What Code Should I Report for a Repair Due to Injury?

On the other hand, if the surgeon performs the repair because of an injury, you will use 57200 (Colporrhaphy, suture of injury of vagina [nonobstetrical]).

Let’s say a patient slips and catches herself in the shower a week after a total abdominal hysterectomy (58150) and ruptures the sutures at the vaginal cuff and part of the vaginal wall. The ob-gyn returns her to the operating room to repair the cuff and vaginal wall laceration.

In this case, you would report 57200-78. You can report this code because now your diagnosis code (S31.40XA, Unspecified open wound of vagina and vulva, initial encounter) matches the CPT^® code’s description.