Ob-Gyn Coding Alert

Returning to the operating room means 58999.

To select the appropriate code for vaginal cuff repair, you should ask yourself one question: Why did the ob-gyn need to perform the repair? The answer may pave to the way to the correct code choice.

Circumstances Make the Difference

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

For example, was it part of a staged procedure related to a previous surgery, caused by loosening sutures or injury, or some other reason?

If you have to return to the operating room for a vaginal cuff repair because the original sutures became loose, you should report 58999 (Unlisted procedure, female genital system (nonobstetrical)), and compare the work to 57200 (Colporrhaphy, suture of injury of vagina [nonobstetrical]).

Watch out: You should not report 12020 (Treatment of superficial wound dehiscence; simple closure), because the vaginal cuff is not part of the integumentary system. While 12020 may be a close approximation to the repair performed, this code does not capture all the work that would be required.

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 global period for the previous surgery, says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin.

Example: Approximately a week after undergoing 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]), the patient notices vaginal bleeding. The ob-gyn takes her back to the operating room and must repair the vaginal cuff because of ruptured sutures. In this case, you would report 58999-78.

Get the Measurements for Complex Repair

If the ob-gyn notes the size of the repair in the operative note and it meets the definition of a complex repair, you can use 13131-+13133 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet ...).

Because these codes merely reference “genitalia,” they can include internal structures of the vaginal canal, experts say.

According to CPT^®, a complex repair “includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement, (e.g., traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. “For instance, the ob-gyn in the previous example documented that the vaginal cuff repair was 3 cm long and required layered closure with some wound debridement of a traumatic laceration. Here, you would report 13132 (... 2.6 cm to 7.5 cm) because the physician recorded the repair size and characteristics indicative of a complex repair.

Exception: On the other hand, if the surgeon performs the repair because of an injury not related to surgery, you would use 57200 (Colporrhaphy, suture of injury of vagina [nonobstetrical]).

Let’s say a patient sustains an injury to vaginal canal as a result of falling off a bicycle. The ob-gyn might take her to the operating room to repair the injury. In this case, you would report 57200.