Ob-Gyn Coding Alert
No Layered Repair? Then Strike "Complex" from Your Options
Question: My ob-gyn performed an episiotomy revision in the office 8 months after the delivery. His documentation states:
“Perineum cleaned with Zephiran, local 1% Xylocaine injected into site directly 3 ml. The scar from the hymenal ring to the external perineum is incised and removed. The mucosa is reapproximated with 4-0 Vicryl. EBL is nil. She tolerated this well.”
How should I code this?
Maryland Subscriber
Answer: Based on the physician documentation, he removed something more akin to a lesion with simple repair.
You should not consider this a complex repair, because a complex repair would describe a scar revision with a layered repair. The ob-gyn did not describe a layered repair, even though he removed the scar.
Therefore, you should go with the benign excision code (11420-11426, Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia ...). You will select the correct code by the length of the area removed.
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