Ob-Gyn Coding Alert

Question: How should I report this? Patient was initially scheduled for an ANTERIOR & POSTERIOR REPAIR WITH PERINEORRHAPY (57260/57265). However, the operative report below describes something different. I’m trying to decide what CPT^® codes to use instead. To me, the operative report describes more of a 57250 and 57268, but I wanted a second opinion.

PREOPERATIVE DIAGNOSIS: 1. Cystocele 2. Rectocele

POSTOPERATIVE DIAGNOSIS:

1. Enterocele 2. Rectocele

PROCEDURE PERFORMED: Repair of enterocele and posterior repair

DETAILS OF PROCEDURE: The patient was taken to the operating room where satisfactory anesthesia was induced. She was placed in lithotomy position, prepped and draped in a sterile manner. Exam under anesthesia revealed no pelvic masses, the absence of the uterus. She had a very small-capacity vagina, and on careful exam what we really see is that she had a very short anterior vaginal wall and then enterocele and rectocele and a somewhat longer posterior vaginal wall. That was the impression at the time of the exam under anesthesia.

The vaginal epithelium was infiltrated with lidocaine plus epinephrine solution and then a transverse incision created at the junction of the perineal skin and the posterior vaginal epithelium. The Metzenbaum scissors were then inserted in the space between the vaginal epithelium and the underlying rectal and perirectal tissues in the midline and these were dissected or separated away from the rectal and perirectal tissues in the plane that existed between these two, and then the vaginal epithelium was incised in the midline. This procedure was repeated from the vaginal opening up to the apex of the vagina in the midline, always in the midline, always separating the underlying tissues from the overlying vaginal epithelium.

A rectal exam was then performed to find the location of the rectum. The rectocele proceeded from near the vaginal opening fairly high up into the vagina, but at the very apex there was a small enterocele also noted. The enterocele sac was dissected free of surrounding tissues, excised and closed in a purse string manner. I then used interrupted Vicryl sutures to approximate the deeper perirectal fascial-type tissues over the rectum to restore it to its normal anatomic position and then trimmed the vaginal epithelium with all clamps, etc. off the epithelium to make sure we got just the right width. Again, because we had a small-capacity vagina to begin with, especially in terms of the length of the vagina care was taken to do this quite precisely and not over trim. The vaginal epithelium was then closed using a running Vicryl suture. The perineal body was reapproximated in the manner of second-degree episiotomy repair using interrupted 0 Vicryl sutures and then the superficial skin of the perineum was closed using subcuticular Vicryl suture. Sponge and needle count correct.

FINDINGS: It should be noted that at the location of the enterocele, the bladder did come quite down close as one would anticipate, but definitely no cystocele was noted. The bladder came close to the area where we entered to do the enterocele, so the apex of the vagina was basically the bladder and the enterocele.

Wyoming Subscriber

Answer: You are correct. The documentation clearly supports both the repair of a rectocele and an enterocele. Therefore, you would bill both codes 57268 (Repair of enterocele, vaginal approach (separate procedure)) and 57250 (Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy). However, as 57250 has greater relative value units than 57268, you would list that code first. Also note that even though 57268 is identified in CPT^® as a separate procedure, you can bill both code together without hitting a National Correct Coding Initiative (NCCI) edit.