natashalage
Expert
Hello OBGYN Team,
Could you please tell me what CPT you will choose for this case? Thank you very much for your rational!
Dx; perineal pain at site of stitches from 4th degree laceration a few weeks ago.
Procedure Performed: exam under anesthesia with removal of knots and repair of perineal skin
Findings:
1) intact perineal body, external and internal anal sphincter, separation of skin along upper 2/3of perineum.
2) granulation tissue
On exam, the rectal mucosa was examined and intact; the perineal body and sphincters were palpably intact. The vaginal repair was intact. There was good rectal tone. The upper 2/3 of the perineal skin was separated and two knots of PDS were seen, grasped and removed with scissors. With palpation, two other PDS knots were found and removed with scissors. Copious irrigation was undertaken. The exposed skin was healthy with no evidence of infection. 10mL of 2% lidocaine was injected locally. Scalpel and Metzenbaum were used to remove a small amount of fibrous tissue and granulation tissue. 3-0 Vicryl was used to close the perineal tissue and skin. At the to cover the knot at the superior aspect, 4-0 Vicryl was used in a subcuticular fashion at the introitus. 10mL of 0.25% bupivacaine used for post op pain control.
Granulation tissue was present in the vagina and removed with scissors and treated with silver nitrate. Urojet lidocaine was used on these areas.
MY RATIONAL: if it was a repair of the Original laceration, i would go with 12041- Repair, intermediate...etc but because it was 'separation of the skin' of the old repair= dehiscence O90.1, I am choosing between 12020 or 13160.
12020- Treatment of superficial wound dehiscence; simple closure. There has been a breakdown of the healing skin either before or after suture removal. The skin margins have opened. The physician cleanses the wound with irrigation and antimicrobial solutions. The skin margins may be trimmed to initiate bleeding surfaces. Report 12020 if the wound is sutured in a single layer
13160- Secondary closure of surgical wound or dehiscence, extensive or complicated. The physician secondarily repairs a surgical skin closure after an infectious breakdown of the healing skin. After resolution of the infection, the wound is now ready for closure. The physician uses a scalpel to excise granulation and scar tissue. Skin margins are trimmed to bleeding edges. The wound is sutured in several layers.
To me, it was not a complicated, extensive repair; therefore, I would choose 12020. Do you agree? Thank you very much!
Could you please tell me what CPT you will choose for this case? Thank you very much for your rational!
Dx; perineal pain at site of stitches from 4th degree laceration a few weeks ago.
Procedure Performed: exam under anesthesia with removal of knots and repair of perineal skin
Findings:
1) intact perineal body, external and internal anal sphincter, separation of skin along upper 2/3of perineum.
2) granulation tissue
On exam, the rectal mucosa was examined and intact; the perineal body and sphincters were palpably intact. The vaginal repair was intact. There was good rectal tone. The upper 2/3 of the perineal skin was separated and two knots of PDS were seen, grasped and removed with scissors. With palpation, two other PDS knots were found and removed with scissors. Copious irrigation was undertaken. The exposed skin was healthy with no evidence of infection. 10mL of 2% lidocaine was injected locally. Scalpel and Metzenbaum were used to remove a small amount of fibrous tissue and granulation tissue. 3-0 Vicryl was used to close the perineal tissue and skin. At the to cover the knot at the superior aspect, 4-0 Vicryl was used in a subcuticular fashion at the introitus. 10mL of 0.25% bupivacaine used for post op pain control.
Granulation tissue was present in the vagina and removed with scissors and treated with silver nitrate. Urojet lidocaine was used on these areas.
MY RATIONAL: if it was a repair of the Original laceration, i would go with 12041- Repair, intermediate...etc but because it was 'separation of the skin' of the old repair= dehiscence O90.1, I am choosing between 12020 or 13160.
12020- Treatment of superficial wound dehiscence; simple closure. There has been a breakdown of the healing skin either before or after suture removal. The skin margins have opened. The physician cleanses the wound with irrigation and antimicrobial solutions. The skin margins may be trimmed to initiate bleeding surfaces. Report 12020 if the wound is sutured in a single layer
13160- Secondary closure of surgical wound or dehiscence, extensive or complicated. The physician secondarily repairs a surgical skin closure after an infectious breakdown of the healing skin. After resolution of the infection, the wound is now ready for closure. The physician uses a scalpel to excise granulation and scar tissue. Skin margins are trimmed to bleeding edges. The wound is sutured in several layers.
To me, it was not a complicated, extensive repair; therefore, I would choose 12020. Do you agree? Thank you very much!
