Ob-Gyn Coding Alert

Question: My ob-gyn performed a lysis of postpartum vaginal adhesions. Should I report 623.2? The CPT code is what confuses me. How should I report adhesiolysis of vaginal adhesions?


Colorado Subscriber

Answer: Because you seem to be indicating that the adhesions were the result of the pregnancy, under ICD-9 guidelines you should consider this a late effect of pregnancy if the initial postpartum period is over.

Therefore, you should code the current problem. You should report the adhesions noted by 623.2 (Stricture or atresia of vagina), followed by 677 (Late effect of complication of pregnancy). If the patient is still in the postpartum period, the diagnosis will be 665.84 (Other specified obstetrical trauma; postpartum condition or complication).

Similarly, your procedure code will depend on whether the patient is still in the postpartum period. You should use 58999 (Unlisted procedure, female genital system [nonobstetrical]) if she is outside the global ob period or 59899-78 (Unlisted procedure, maternity care and delivery; return to the operating room for a related procedure during the postoperative period) if she is not.
 
Note: You should offer a detailed description of the procedure the ob-gyn performed. Don't forget documentation of medical necessity to back up the decision to perform the procedure, as well as the time, effort and equipment the ob-gyn used.

The answers for Reader Questions and You Be the Coder were provided by Melanie Witt, RN, CPC-OGS, MA, an ob-gyn coding expert based in Guadalupita, N.M.