Ob-Gyn Coding Alert

Question: Our ob-gyn documented the following:

Findings: On exam under anesthesia, the patient was found to have only a 3 mm vaginal opening due to a previous procedure done in Africa that involves excision of both labia minora and reapproximation over the midline covering the vaginal opening, urethra, and clitoral hood.

At this time, the midline ateriorly from the vaginal opening was infiltrated with lidocaine with epinephrine, and needled and a Rankin was used to track underneath the skin to confirm the skin was elevated away from the vaginal opening and urethra. Rankin was then opened and needlepoint cautery was used to open the skin in the midline up above the urethra to just under the clitoris. There was excellent hemostasis. The vagina was easily entered with a small probe, and hymen was noted to be intact. Urethra appeared grossly normal. At this time, a 4-0 Vicryl running suture was used to close the opening, approxi­mating the vaginal mucosa with the skin to allow for better healing, and Premarin cream was applied.

At the completion of the procedure, sponge and needle counts correct x2, and patient was taken to recovery in stable condition.

What should I report?

Texas Subscriber

Answer: A revision of a female circumcision tends to be more reconstructive in nature, so a code like 56800 (Plastic repair of introitus) is appropriate.

Potential diagnosis codes are N89.5 (Stricture and atresia of vagina) or N90.8- (Female genital mutilation).