Ob-Gyn Coding Alert

READER QUESTIONS:

Question What Caused Scar Tissue

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?


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. 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.
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