Ob-Gyn Coding Alert

Question: Patient has a cyst on Skene’s gland, and I’m trying to find a procedure code. The procedure note says the following:

Patient was given IV anesthesia and prepped with Betadine. Exam revealed a smaller cystic area than earlier in the week but still palpable. Catheter was placed in the urethra to allow separation from the cyst. The overlying tissue was injected with 1% lidocaine with epi. 2 cc used. The overlying tissue was opened sharply with scalpel. There was return of mix of old blood/mucous. The cyst wall was sewn open with interrupted 2-0 chronic to keep it open. There was minimal bleeding. The catheter was removed. The patient went to recovery in satisfactory condition.

What should I report for this?

Kansas Subscriber

Answer: As you suspect, you won’t find any code for this procedure — just one for an incision and drainage (I&D) of Skene’s gland or cyst or the excision/fulguration of the gland, which is not what the ob-gyn did. He has described marsupialization of the gland.

You could try 53060-22 (Drainage of Skene’s gland abscess or cyst; Increased procedural service) for this procedure. Another option is 58999 (Unlisted procedure, female genital system [nonobstetrical]) and compare the work to 56440 (Marsupialization of Bartholin’s gland cyst).