Ob-Gyn Coding Alert
Declare Victory Over This Vaginoperineoplasty Scenario
Question: What’s the best way to code the vaginoperineoplasty portion of this procedure: FINDINGS: DESCRIPTION OF PROCEDURE: Washington Subscriber Answer: You should report 56800 (Plastic repair of introitus) because he is repairing the vaginal outlet. Also, your secondary code will be the IUD insertion, 58300 (Insertion of intrauterine device [IUD]). Your diagnosis code will include Z30.430 (Encounter for insertion of intrauterine contraceptive device). Also, since the repair was required due to a late effect of the perineal laceration, you will report a O70.1 (Second degree perineal laceration during delivery), and a secondary diagnosis of O94 (Sequelae of complication of pregnancy, childbirth, and the puerperium). You may report an obstetric postpartum complication beyond the 6 weeks postpartum period according to the ICD-10 guidelines.
Shortened vaginal outlet secondary to vaginal scarring from second degree laceration after delivery and also 9 cm uterus.
The patient was taken to the operating room where she was properly identified as herself. Appropriate timeout was performed. The patient was prepped and draped in the normal sterile fashion in a dorsal lithotomy position. The patient was examined under anesthesia and found to have a small anteverted uterus but also abnormally shortened vaginal outlet. The posterior fourchette of the vagina was incised via a diamond incision drawing from bilateral ends of the vulva down to the perineum and this was also extended internally into the vagina. Once this tissue was removed, the incision was closed anteriorly to posteriorly with good hemostasis noted throughout. There was Pitressin and lidocaine used during the procedure to help and control vaginal bleeding. Approximately 10 cc of the solution was used. Once the vagina was noted to be of normal caliber, the IUD was taken and placed into the uterus uneventfully. The patient was sounded to 9 cm and the strings were cut to approximately 3 cm in length. The speculum was removed from the vagina and again a second look at the perineum was noted to be hemostatic. At this point, the procedure was terminated.
Related Articles
Ob-Gyn Coding Alert
- ICD-10 2020:
Get Ready for New Post Endometrial Ablation Syndrome, Pyuria Diagnoses
When a breast lump overlaps anatomical sites, use these new codes. You’ve got a new [...] - Modifiers:
Bust These 5 Modifier 24 Myths to Boost Your Ob-Gyn's Bottom Line
Hint: Focus on the documentation, not the diagnosis codes. To ensure payment for E/M services [...] - Gynecology:
Execute Perfect Enterocele Combo Claims With This Expert Advice
Do you know how to report a “modified radical” abdominal procedure? Find out. If you’re [...] - You Be the Coder:
Careful Which Code You Submit as Primary
Question: We billed CPT® codes 58552 and 49322-59 because of additional documentation from the provider. [...] - Reader Question:
Declare Victory Over This Vaginoperineoplasty Scenario
Question: What’s the best way to code the vaginoperineoplasty portion of this procedure: FINDINGS:
Shortened [...] - Reader Question:
Contemplating a Robotic Surgery Surcharge? Read This First
Question: I know that very few payers reimburse at all for S2900 (Surgical techniques requiring use [...] - Reader Question:
Highlight These Initial, Follow-Up Ultrasound Codes
Question: What is the CPT® code for initial anatomy ultrasound at 15 weeks gestation and the CPT® code [...]
