Ob-Gyn Coding Alert

Question: My physician documented: "Open of the vaginal cuff with evacuation of the hematoma and re-suturing of the vaginal cuff." Should I use 57022 or 57023 for this? The patient is not postpartum (57022) but she is having this done 2 weeks after having a trachelectomy (removal of cervix), so would this be considered a trauma? She opened the vaginal cuff to suction the vaginal hematoma, and then resutured it. So would it then be 57023, since she did do it to remove the vaginal hematoma? I'm leaning more towards 57023 with modifier 78 (return to or) just because it's not postpartum. But I don't think it's necessarily "post-trauma." Am I correct?

Virginia Subscriber

Answer: No. You should use the unlisted procedure 58999-78 (Unlisted procedure, female genital system [nonobstetrical]; Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period), but you can compare the work to 57023 (Incision and drainage of vaginal hematoma; non-obstetrical [e.g., post-trauma, spontaneous bleeding]). 

This is a surgical complication to the cuff and not removal of a hematoma from the vaginal wall, which is the intent of code 57023. Your diagnosis will be 998.12 (Hematoma complicating a procedure).

Note: The physician did not remove a vaginal wall hematoma, which is represented by the work of 57023. She opened the suture of the cuff to remove a hematoma in the peritoneal cavity (the space that was left after they removed the uterus). This is why 57023 would not be accurate. It's close, but CPT® states that this is not the correct way to select a code.  

To quote CPT® "Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT® code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code."

ICD-10: When your diagnosis system changes to ICD-10, code 998.12 will become N99.820 (Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following a genitourinary system procedure). In this case, documentation will be key to getting to the right code because ICD-10 also includes codes for intraoperative hemorrhage and hematoma, as well as a code for the postoperative complication, but after a different type surgery than GU surgery.