Ob-Gyn Coding Alert

Question: My ob-gyn listed the procedure as perirectal cystectomy and pre-op diagnosis as Bartholin gland cyst, so I need some help.

Op note reads: “Patient taken to OR and exam revealed golf ball size cyst at 7-8 o’clock surrounding the vaginal cavity. The cyst was palpated to extend to but not into the rectum. Digital rectal exam confirmed cyst with no opening into the rectal canal. Approx 3-cm incision was made along the axis of the vagina at the external portion of the vaginal canal. The cyst was palpated digitally. Using blunt dissection, the cyst was isolated; however, during trying to manipulate and isolate the cyst, it spontaneously ruptured. Dark material was removed and the cyst wall itself was isolated using Allis clamps and the surrounding tissue was sharply dissected off with Metzenbaum scissors. Continuing in this fashion, the cyst was removed. Digital rectal exam confirmed cyst had been removed, rectal mucosa was intact. Next, using 2-0 Vicryl, the space created where the cyst was closed with interrupted sutures. 2-0 Vicryl was used to close the vaginal mucosa starting at the apex and in a running interlocking fashion until all the way down to the hymenal ring. No vaginal packing done. Instrument removed and counted.”

The postoperative diagnosis report stated, “suspected perirectal cyst,” so I looked at the path report also and it states “perirectal tissue-perineum-excision of perirectal cyst like structure.”

What should I report?

Florida Subscriber

Answer: In this case, you have verified with the path report that it was a perirectal cyst and not a Bartholin’s gland cyst, so your code choice will be 11420-11426 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia …) and not 56740 (Excision of Bartholin’s gland or cyst). He also did a layered closure, so you can also report an intermediate repair code (12041-12047, Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; …). The repair code you choose should match the size of the lesion removed.

Bottom line: You need to check with provider about the size of the lesion with margins to pick the correct procedure code.