Urology Coding Alert

Question: My urologist performed the following procedure, and the doctor suggested 56441 but that doesn’t seem correct. So based on the following documentation, what should I report?

“After informed consent was verified with patient she was brought back into the OR and positioned supine. She was prepared for local/MAC anesthesia. The patient received pre-operative Ancef IV. After timeout was performed the patient was prepped and draped in the lithotomy position. Cystoscopy was performed showing a normal urethra and bladder neck, there were mild trabeculations to the surface of the bladder. The trigone and ureteral orifices were identified and appeared normal, there was noted to be a degree of descent of the floor of the bladder, likely related to prior vaginal surgery. On digital examination and direct visualization there were noted to be 3 small skin bridges about 5 mm in size each as well as a larger skin bridge about 1.5 cm in width making the anterior vaginal wall adherent to the posterior vaginal wall. After infiltrating and injecting 0.25% plain Marcaine into each of these bridges they were lysed using electrocautery. Hemostasis was achieved and a 4-0 Vicryl figure-of-8 was placed on the posterior vaginal wall transected portion of the largest bridge. The wound was irrigated and hemostasis confirmed. A clindamycin-treated Kerlix gauze was packed prior to arousing the patient and transferring her back to PACU in stable condition.”

California Subscriber

Answer: You are correct that 56441 (Lysis of labial adhesions) is not the correct code for this procedure as the adhesions were within the vaginal canal and not between the labia. Instead, you should report 57061 (Destruction of vaginal lesion(s); simple [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery]).  

Append ICD-9 code 623.8 (Other specific non-inflammatory disorders of vagina, ICD-10: N89.8, Other specific non-inflammatory disorders of vagina) or ICD-9 code 701.5 (Other abnormal granulation tissue, ICD-10: L92.9, Granulomatous disorder of the skin and subcutaneous tissue, unspecified).