Question: I-m looking for a code for excision of scar tissue in the right vaginal fornix. The provider did suture a couple of areas. Would 56800 be correct, or is there something better to use? 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.
Maryland Subscriber
Answer: Your answer will depend on your ob-gyn's documentation. What caused the scar tissue? Was it an injury?
You can only use 56800 (Plastic repair of introitus) for repair of the introitus. Keep in mind: This location is about as far away from the vaginal fornix as you can get.
Use 58999 (Unlisted procedure, female genital system [nonobstetrical]) or 57200 (Colporrhaphy, suture of injury of vagina [nonobstetrical]) if this scar is due to a previous injury.