Surely you don't honestly expect to have the last word on this issue. I can deal with the fact that the remnant cuff may not be cervical tissue - the code assignments I suggested are not going to work for this scenario with the documentation provided - I'm big enough to admit that I don't know everything. The forums provide a trivia-type learning platform for me - I don't expect to have all of the right answers every time, and I use the mistakes I make as an opportunity to learn something new. I am not an expert by any means; as far as I'm concerned, I'm still a student. Now, if we're done dwelling on the fact that I was wrong about my code assignment, maybe we can address the mistakes that you have made in your advice. Let's compare what you've suggested with the original OP note, as we did with mine.
"Operative Indications:
53 y/o gravida 3, para 3 status post vaginal hysterectomy w/colporrhaphy several years ago who reports dyspareunia point tenderness in the apex of the vagina during intercourcse. The patient has recently been treated for vaginal atrophy w/some improvemtn, although the patient reports there is still tenderness at the area and desires removal of the cuff remnant.
Operative Technique:
Patient was brought to the OR. A time out was performed. She was prepped and draped in a normal sterile fashion in the dorsal lithotomy postion. Her legs were placed in candy cane stirrups. Initially it was through that a LEEP instrument would be good to remove the remnant; however, upon revisualization of the vaginal cuff and considering the narrowness of her vagina this was not done. Instead a 15-blade scalpel was used to excise the less than 5-mm remnant. Minimal estimated blood loss was present. Pressure was held at the area of bleeding and a small amount of Monsel was placed at the area of the excision for hemostasis. Please not that prior to the beginning of the case bimanual examination was done as well as emptying the bladder. The vaginal canal was reinspected after removal of the remnant. The mesh was palpated at the posterior aspect of evidence of room for a surgical expansion of the vaginal length or width. The case was then ended. The sponge, lap and needle counts were correct times two. Please note that also prior to the beginning of the case a bolus solution of lidocaine with epinephrine 1:100,000 was used and less than 1 ml was injected in the vaginal cuff remnant that was to be removed."
Let's start at the beginning:
"Post Vaginal Hysterectomy wih colporrhaphy done many years ago- that means the Cervix is totally removed along with the body of the uterus, There is no cervical stump left behind. So it is NOT cervial tissue." Your first statement is based off of an assumption. The note does not say "Radical hysterectomy" or "trachelectomy", or even "total hysterectomy". In fact, there's no indication at all that the cervix was ever removed. A colporrhaphy alone does not imply that all cervical tissue has been removed - the two are not synonymous, and one does not serve as a pre-requisite to the other. So, regardless of any code I've mentioned at any point in time, your belief that there is no cervical tissue whatsoever is based off of a conclusion that you jumped to; there is no factual basis in the records provided. Everything you suggest is contaminated by this initial fabrication.
Assumption #2:
"Colporraphy done with a Mesh left. So the tissues could be the redundant portion tag of the vaginal tissues (which could happen while the process of healing of the approximated site of vaginal incisional margins) or a new growth of tissue. there is no possibility of any other tissue jutting out there to merit its presence." Colporrhaphy done with mesh left? How do you know that? Did you see it? It certainly wasn't documented. You then proceed to provide more conjecture about the situation with no support in the context of the medical record. Take note of the phrases I've underlined. "Could" = "I'm guessing". Once you finished re-creating this patient's surgical history in the image you dreamed up, you reinforce your correct-ness by referencing the flawed "facts" you bestowed on this case in the first case, with the claim that there is no possibility the tissue could be anything other than what you say.
Your advice:
"As such I would give 57135 excision of tumor/cyst or any vaginal core or mass of tissues , until and otherwise the pathology report comes different." There are several things wrong with this statement. First, there is no mention whatsoever of any cyst or tumor in the note. Zip. Zilch. Nada. Go ahead - check it again. It's not there. There's also no indication at all that there would ever be a pathology report, or that the physician even had the slightest suspicion of a pathological connection to the problem. Take note of the absence of words like "sampling", "biopsy", "malignancy", and any other term that might point to a disease or illness. The record isn't even clear as to the reason for the initial hysterectomy. There's not enough history or description provided to point to any specific code assignment - the note is just too vague.
Also, the phrase "or any vaginal core or mass of tissues" is NOT part of 57135's code description. You don't have the authority to re-write the CPT manual for your convenience, so don't add things that aren't there.
You often tout your expertise and cite your decades of experience (although this is the first time you've also mentioned your medical degree). I'll be frank; you've given bad advice here. By "bad advice", I don't mean that you've given an answer that is incorrect, per se. I mean that you are advocating the complete fabrication of details that have a significant impact on code selection, and ignoring the most basic principles of ethical and correct coding, because you're certain that you're right. I hate to be the bearer of bad news, but that's about as wrong as one can get. I don't care if you've had 5 days of coding experience, or 50 years. You could have literally written the book on the subject; it doesn't matter. Medicine is not black and white, with cookie-cutter scenarios that follow the same prescribed course for every person, every time. It is not okay to utilize conjecture to apply specificity to a situation, in the complete absence of supporting evidence. You do not code based on information that doesn't exist in the medical record. Ever. It can and will be construed as fraudlent billing practices, for good reason. It is not our place to fill in the blanks to supplement insufficient documentation. The physician in this case should be asked to provide clarification, by appending the official record. Otherwise, an accurate and specific code assignment will not be possible.
Ordinarily I prefer to let disagreements go once I understand the conflict, and I try not to come across as condescending, but at the present moment, I'm not doing a very good job of either. I have to draw the line somewhere, and although I can usually put up with your apparent superiority-complex (during the frequent occasions I've encountered it), I will not tolerate being treated like an imbecile by anyone, particularly when they are so cavalier about rationalizing their answers using non-existent "facts". You really don't have to take every slight critique of your answers as a personal insult. It's ridiculous, and it makes you seem petty; it's certainly not earning you any credibility. Drawing plausible, alternative conclusions regarding the code selection in some cases is not only possible, but is essential to ensuring that every angle of the situation has been inspected by people with differing points of view. Attacking others for simply having the audacity to question your judgement, and refusing to admit that you could actually be wrong, will not make you any more correct. You are not infallible; your logic is not perfect, and your expertise does not entitle you to bend the rules, or berate others for having an opinion that contradicts yours. You don't have to win every argument, even by sheer willpower. Rather than getting all huffy when your reasoning is challenged, just accept that not everyone has had the benefit of being you, therefore they may have a different take on things. No one will condemn you for acting like you've got a little bit of humility.