Ob-Gyn Coding Alert

Question: My ob-gyn documented the following:

20 cc of lidocaine injected into the laceration site observed at the time of delivery. A rectal exam was performed and there was noted to be an approximately 1cm tear into the rectal mucosa. The rectal mucosa was repaired with a running suture of 3-0 Vicryl and a second imbricating layer was placed. Only 2-3 stiches required. A rectal exam confirmed no sutures in the rectum. Allis clamps were used to grasp the internal anal sphincter bilaterally and 3 interrupted sutures were placed through the IAS. The external anal sphincter was reapprox­imated with mattress sutures. The second-degree laceration was then repaired in the usual fashion with 2-0 Vicryl Rapide reapproximating the vaginal mucosa deeper subcutaneous tissue in a running locked fashion. The perineal skin was reapproximated 3-0 Vicryl Rapide in subcuticular fashion. Rectal exam confirmed good tone and repair.

Would CPT^® 13131 be appropriate, or should I just use 59400 with modifier 22?

South Dakota Subscriber

Answer: You should not use 13131 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm), because you should not classify this as a complex repair. There was no debridement or extensive undermining of the laceration. At best, this was an intermediate repair of the anus and rectal mucosa-neither of which has its own specific CPT^® code.

Also, you should not consider this to be "external genitalia," so the intermediate repair codes would also not be correct.

You can use the unlisted code 45999 (Unlisted procedure, rectum) or 46999 (Unlisted procedure, anus) and compare the work to an 1205X CPT® code. However, you will need to know the repair measurements. Another option, as you have suggested, is to apply a modifier 22 (Increased procedural service) to the global OB code (59400, Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care). You'll need to make a case for additional payment.