Robin Posted 5 Year(s) ago
My doctor wants to proceed with surgery on a patient. She will be doing Excision vaginal cuff granulation tissue under anesthesia. What code should I use for this?
SuperCoder Posted 5 Year(s) ago
For the repair/excision of the vaginal cuff, you will be confined to using 58999 (Unlisted procedure, female genital system [nonobstetrical]). Be sure to submit your op report along with a cover letter that explains in simple, straightforward language exactly what your ob-gyn did. Remember to explicitly reference the nearest equivalent listed procedure in your explanatory note.
As a diagnosis, you should use 616.8 (Other specified inflammatory diseases of cervix, vagina, and vulva) -- if this procedure is happening quite some time following the original surgery. If the ob-gyn indicates that this involves disruption of the internal sutures, you can use 998.31 (Other complications of procedures, not elsewhere classified; disruption of internal operation wound).
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