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Ob-Gyn Coding Alert

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Use Unlisted Procedure for Vaginoplasty Repair

Published on Thu Feb 05, 2009

Question: Our ob-gyn created a neo-vagina for agenesis for a patient. He modifies it six days later. The ob-gyn wanted to bill 57410 (Female pelvic examination under anesthesia), but his work indicates more than that. The original code was 57292 (Construction of artificial vagina; with graft). Should I report the succeeding procedure as 57291 (Construction of artificial vagina; without graft)? Should I use modifier 58 or 76?

The findings indicate:

"Patient was six days postoperative following a McIndoe split-thickness skin graft vaginoplasty with the skin harvested from the right upper thigh. The surgeon placed a suprapubic catheter and when he examined the vulva, it revealed significant labial edema and swelling.

There were three retention sutures that held the vaginal mold in place. The surgeon placed the sutures to approximate the labia majora. After their release, the surgeon found that the vaginal mold was  significantly displaced from the vaginal canal and was retained behind the labia majora.

In the vaginal canal was a significantly-sized old blood clot. Careful evaluation of the neovaginainitially showed that there was a complete take of the skin graft. However, later, upon insertion and removal of the vaginal mold, there was some disruption of the distal posterior vaginal wall and some of the not wellattached vaginal mucosa was excised here.

The surgeon took a skin graft, estimated at about 80 percent at the completion of the procedure. He inserted a Petersen speculum at about 7.5 cm of vaginal depth. The surgeon noticed that there was some narrowing of the vagina as one viewed the apex. Consequently, he fashioned a new foam rubber sterile mold and inserted it. He left the suprapubic catheter in place."

Should I report 57291-58, 57292-76, or 57410?

Virginia Subscriber

Answer: You should bill this as an unlisted procedure with 58999 (Unlisted procedure, female genital system [nonobstetrical]). This service is not more extensive than the original procedure, nor was it planned prospectively, so modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) does not apply. Moreover, the ob-gyn is not repeating the same procedure (modifier 76, Repeat procedure by the same physician), just fixing it.

When reporting an unlisted procedure code, you have to let the payer know how to judge that your charge is reasonable based on the physician work. For this procedure, some graft revision occurs. Since the mold is used to hold the graft in place, however, the ob-gyn doesn't get extra credit for that graft work.

Better: Check with your surgeon to see what procedure he would like to compare this work to in order to set your fee. You should also let the payer know an equivalent of the approximate amount of work. For instance, the work might be close to 57295 (Revision [including removal] of prosthetic vaginal graft; vaginal approach), even though this is not that type of vaginal graft.

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