Ob-Gyn Coding Alert

Question: Patient had LEEP for CIN 3 yesterday. Started bleeding around 6 pm last night and changed pad per hour overnight. Presented to ED early this AM. In ED, was found to have oozing from cervix and MD called our office. Patient was stable with Hgb of 12 and therefore D/C from ED and presented immediately to clinic.

On exam, cervix with only very small amount of bleeding from right edge of LEEP bed. Patient reported loop touched right side of vagina during procedure yesterday and was very painful. Exam of right vaginal side wall revealed approx 3 cm laceration which was fairly superficial but was actively bleeding. Cervix and vaginal side wall infiltrated with 1.5 vials of 2% Xylocaine with Epinephrine, 1.8 mL in each vial (majority in cervix, very small amount into vaginal wall). 4-0 vicryl used in running fashion to close laceration. Hemostatic after repair. Ball cautery then used on edges of LEEP bed to provide hemostasis in this area as well.

What should we report?

Texas Subscriber

Answer: Your diagnosis will be a complication code following a procedure, which is N99.820 (Postprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedure), and N99.71 (Accidental puncture and laceration of a genitourinary system organ or structure during a genitourinary system procedure).

You can try code 57200 (Colporrhaphy, suture of injury of vagina (nonobstetrical)) for the repair of the vaginal wall, as this was an injury.