Advice needed on CPT coding of these services please. Outpatient hospital setting under anesthesia. Patient is about 6 months post op from TVH and has been experiencing vaginal bleeding and friable vaginal tissue. Report reads as follows:
PROCEDURES: exam under anesthesia, removal of vaginal mass
Findings: vaginal friable mass and defect in the vaginal cuff. Mass consistent with fallopian tube
Procedure patient was taken to the operating room She was prepped and draped in the normal sterile fashion. Legs were placed in allen stirrups. A weighted speculum was then inserted vaginally. The vaginal cuff was identified and grasped at the edges with allen graspers. In the midline friable mass that had been noted in the office was clearly identified. Appeared to be arising from the peritoneal cavity through a defect in the vaginal cuff anatomy consistent with fallopian tube and fibrae. A suture was placed around the mass. A section of the mass was then excised and sent to pathology for identification. The remainder of the likely tube was then placed back in the peritoneal cavity through the defect. Edges of the defect were inspected and cauterized with Bovie cautery. That area of the cuff was then was sutured with 0' vicryl suture. The area was examined one last time and found to be completely hemostatic following irrigation. All instrumentation was removed from the vaginal canal all sponge lap needle counts were correct x 2.
I am debating using the following CPT's : 57285 Paravaginal defect repair & 57061 destruction of vaginal lesion vs 57135 excision of vaginal cyst/tumor vs 58999 unlisted procedure? If it is part of her remaining fallopian tube then it wouldn't be a mass/lesion, so I'm leaning towards the unlisted procedure. Help please.
PROCEDURES: exam under anesthesia, removal of vaginal mass
Findings: vaginal friable mass and defect in the vaginal cuff. Mass consistent with fallopian tube
Procedure patient was taken to the operating room She was prepped and draped in the normal sterile fashion. Legs were placed in allen stirrups. A weighted speculum was then inserted vaginally. The vaginal cuff was identified and grasped at the edges with allen graspers. In the midline friable mass that had been noted in the office was clearly identified. Appeared to be arising from the peritoneal cavity through a defect in the vaginal cuff anatomy consistent with fallopian tube and fibrae. A suture was placed around the mass. A section of the mass was then excised and sent to pathology for identification. The remainder of the likely tube was then placed back in the peritoneal cavity through the defect. Edges of the defect were inspected and cauterized with Bovie cautery. That area of the cuff was then was sutured with 0' vicryl suture. The area was examined one last time and found to be completely hemostatic following irrigation. All instrumentation was removed from the vaginal canal all sponge lap needle counts were correct x 2.
I am debating using the following CPT's : 57285 Paravaginal defect repair & 57061 destruction of vaginal lesion vs 57135 excision of vaginal cyst/tumor vs 58999 unlisted procedure? If it is part of her remaining fallopian tube then it wouldn't be a mass/lesion, so I'm leaning towards the unlisted procedure. Help please.
