Ob-Gyn Coding Alert

Question: My doctor took the patient to the OR for an exploration of the vaginal cuff as she is s/p 09/12/19 hysterectomy bilateral salpingectomy. His findings were left vaginal cuff separation, approximately 0.5 cm, pelvic hematoma - 6x4 cm, old suture appreciated at vaginal cuff.

Op report reads: EUA revealed an intraabdominal vaginal cuff mass, the mass was mobile and firm to palpation, speculum placed in posterior fornix and vaginal cuff visualized with the assistance of rt angle retractors. Old suture visualized and removed w/o difficulty. Vaginal cuff was then bluntly dissected and opened with Carmalt’s in a push and spread fashion. No purulent material noted from cuff, cuff was again inspected, and no bleeding was noted at edges. irrigation was carried out until clear. Small amounts of vaginal bleeding were seen coming from behind the vaginal cuff. Arista was placed intravaginally, approximately 0.5 cm x 0.5 cm vaginal cuff opening appreciated w/ good hemostasis noted, instruments removed. I submitted this charge using 58999 and would like to confirm if this was the best coding choice and if so what code would be comparable, I was thinking I could use 57410 or 57200. What should I use as a comparison code?

Wisconsin Subscriber

Answer: You are correct in thinking you can only report this procedure with 58999 (Unlisted procedure, female genital system (nonobstetrical)). The comparison code would be 57200 Colporrhaphy, suture of injury of vagina (nonobstetrical)), not 57410 (Pelvic examination under anesthesia (other than local)). Code 57410 is included in 57200 as a standard of surgical care.