Ob-Gyn Coding Alert

Question: My ob-gyn did:

an excision of vaginal anterior wall mesh and culture,

extensive irrigation of the vaginal wound, and

vaginal mucosa debridement.

This was due to an infection from surgery about two weeks ago involving an A/P repair, total hysterectomy, and vaginal vault suspension. What code(s) should I use?

California Subscriber

Answer: You should report 57295-78 (Revision [including removal] of prosthetic vaginal graft; vaginal approach; Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period). You should include all of the work the ob-gyn performed in this one code, as it was all related to the mesh.  

You will report the diagnosis code 996.65 (Infection and inflammatory reaction due to other genitourinary device implant and graft) for this surgery. ICD-10: When your diagnosis coding system changes, you should report T83.6XX- (Infection and inflammatory reaction due to prosthetic device, implant and graft in genital tract) with the seventh digits representing the encounter type (initial, subsequent or sequelae).