Ob-Gyn Coding Alert

Ask 1 question to get the code you need

To select the appropriate code for vaginal cuff repair, you should ask yourself one question: Why did the ob-gyn need to perform the repair?
 
Probably one of the most frequently asked questions in an ob-gyn office is, Which CPT code should I use for repair of vaginal cuff?"" Unfortunately this is also one of the toughest questions to answer. Consequently everyone seems to have a different opinion about which code to choose. But our coding experts point you in the right direction.

Circumstances Make the Difference

The first thing you should do when the ob-gyn performs a vaginal cuff repair is examine the operative report to determine why the repair was needed says Jean Ryan-Niemackl LPN CPC an application specialist with QuadraMed Government Programs Division in Fargo N.D. For example was it part of a staged procedure related to a previous surgery caused by loosening sutures or injury or some other reason?

If you have to return to the operating room for a vaginal cuff repair because the original sutures became loose you should report 12020 (Treatment of superficial wound dehiscence; simple closure). Be sure to append modifier -78 (Return to the operating room for a related procedure during the postoperative period) if the surgeon performs the repair during the global period for the previous surgery Ryan-Niemackl says.

Example: Approximately a week after undergoing a total abdominal hysterectomy (58150 Total abdominal hysterectomy [corpus and cervix] with or without removal of tube[s] with or without removal of ovary[s]) the patient notices vaginal bleeding. The ob-gyn takes her back to the operating room and must repair the vaginal cuff because of ruptured sutures. In this case you would report 12020-78.

Get the Measurements for Complex Repair

If the ob-gyn notes the size of the repair in the operative note and it meets the definition of a complex repair you can use 13131-13133 (Repair complex forehead cheeks chin mouth neck axillae genitalia hands and/or feet ...) Ryan-Niemackl says. Because these codes merely reference ""genitalia "" they would include internal structures of the vaginal canal adds Melanie Witt RN CPC MA an ob-gyn coding expert based in Fredericksburg Va. According to CPT a complex repair ""includes the repair of wounds requiring more than layered closure viz. scar revision debridement (e.g. traumatic lacerations or avulsions) extensive undermining stents or retention sutures.""

For instance the ob-gyn in the previous example documented that the vaginal cuff repair was 3 cm long and required layered closure of a traumatic laceration. Here you would report 13132 (... 2.6 cm to 7.5 cm) because the physician recorded the repair size and characteristics indicative of a complex repair.

Exception: On the other hand if the surgeon performs the repair because of an injury you would use 57200 (Colporrhaphy suture of injury of vagina [nonobstetrical]) Ryan-Niemackl points out. Let's say a patient slips and catches herself in the shower a week after a total abdominal hysterectomy (58150 Total abdominal hysterectomy [corpus and cervix] with or without removal of tube[s] with or without removal of ovary[s]) and ruptures the sutures at the vaginal cuff. The ob-gyn returns her to the operating room to repair the cuff. In this case you would report 57200-78.

If none of these situations apply you must use the unlisted-procedure code 58999 (Unlisted procedure female genital system [nonobstetrical]) Witt advises. For more on how to best report unlisted-procedure codes see ""Improve Your 'Unlisted Procedure' Pay With 4 Tips"" of the April 2004 Ob-Gyn Coding Alert.

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