Urology Coding Alert

Question: I have a physician who performed a colpocleisis and then a TVT sling. He then stated: "Once the prolapse had been imbricated we directed our attention to the perineorrhapy." The op note states an incision was made through the perineal skin and vaginal mucosa and excised. He dissected the vagina mucosa off the underlying muscles and facia with one finger in the rectum to make sure he did not compromise the rectal mucosa. He placed two sutures through the transverse perineal muscles and distal levators to reapproximate these in the midline and re-create a normal levator plate angle and close the genital hiatus. He usedone suture for this. The vaginal mucosa was then trimmed and then he completed the procedure with a TVT sling placement. I am leaning toward 45560 as opposed to 57250 for the rectocele repair. Which code is the best to use?

Massachusetts Subscriber

Answer: For this procedure, you should report 57250 (Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy).

Here's why: Code 57250 is for the repair of a rectocele with or without a perineorrhaphry and includes a posterior colporrhaphy. In contrast, 45560 (Repair of rectocele [separate procedure]) is for the repair of a rectocele using a perirectal approach without a posterior colporrhaphy. This latter approach is usually peformed by a colorectal or general surgeon. The former is usually performed by a gynecologist or urogynecologist.

Caution: Code 45560, which is listed in CPT®'s Digestive System/Surgery section under Rectum, has only slightly higher relative value units (RVUs) than the posterior colporrhaphy code 57250 (20.45 RVUs versus 19.86 RVUs). And while you might be tempted to use the higher-paying code, beware: if your physician  has described performing a posterior colporrhaphy, even if he does not use that exact terminology, you should report 57250.

How to tell: According to experts, if the procedure contains a posterior colporrhaphy, the op report usually will describe the following elements: a midline incision of the posterior vaginal wall and perineum separation of the vaginal skin from the underlying fascia plication (folding and tacking down with sutures) of the rectovaginal fascia excision of any excess fascia, and plastic repair of the perineum involving suturing together the levator and perineal muscles when indicated.

The procedure described by 45560 is a perirectal approach with the rectocele predominately herniating through the anal canal. The physician dissects the rectocele from the surrounding structures and plicates the rectum to the surrounding fascia. Usually, a general surgeon or a colorectal surgeon performs this procedure to correct a problem of fecal incontinence. 52341/52344 Capture Ureteral Dilatio