Ob-Gyn Coding Alert

Question: The ob-gyn's note reads: "The patient undergoes IV sedation. I infiltrated the area with Xylocaine. By sharp dissection starting just inferior to the posterior fourchette and extending for approx. 2 cm inferiorly in the midline, I released the episiotomy. I discovered significant scar tissue under the epithelial lining. The tract is very superficial. After incising the episiotomy, I repaired 2 layers using 2-0 catgut. Following the repair hemostasis is excellent." 

The patient delivered 3 months ago and was complaining discomfort in the perineal area. He goes on to state, "She had a small defect as well as some adhesions across the midline of her perineal body. On exam, the vagina and anal sphincter is intact. The perineal body is stretched by an adhesion across the midline as well as a 1 cm defect just inferior to this."

Should I code this with 56441, 56810, or a laceration repair?

Tennessee Subscriber

Answer: Neither 56441 (Lysis of labial adhesions) nor 56810 (Perineoplasty, repair of perineum, nonobstetrical [separate procedure]) is applicable because 1) this procedure was not a vulvectomy, and 2) it was obstetrics related. 

You should be using either 59899 (Unlisted procedure, maternity care and delivery) (since it is OB related) and comparing the work to 56810 (which has 7.74 RVUs) or the appropriate intermediate repair code based on size of the repair (12041-12047).