2019 ICD-10 CM code changes coming your way — are you prepared?Join Now >>

Regular Price: $24.95

Ask an Expert Starting at $24.95

Have a medical coding question? Get definitive answers from TCI SuperCoder's Ask an Expert.

Browse Past Questions By Specialty

+View all
Cindy Posted Thu 13th of September, 2012 16:22:11 PM

Diagnosis for procedure is "vaginal peritoneal fistula." Dr. performed a revision of episiotomy. The patient delivered in January so this is not done right after a delivery. I don't think 59300 is an appropriate code. Would this be considered a non-obstetrical vaginal fistula repair code? Thanks for your help.

SuperCoder Answered Thu 13th of September, 2012 20:43:09 PM

I would need to check the exact documentation for this. However it it says like this :

Question: My ob-gyn performed an episiotomy revision in the office 8 months after the delivery. His documentation states:

"Perineum cleaned with Zephiran, local 1% Xylocaine injected into site directly 3 ml. The scar from the hymenal ring to the external perineum is incised and removed. The mucosa is reapproximated with 4-0 Vicryl. EBL is nil. She tolerated this well."

How should I code this?

Maryland Subscriber

Answer: Based on the physician documentation, he removed something more akin to a lesion with simple repair.

You should not consider this a complex repair, because a complex repair would describe a scar revision with a layered repair. The ob-gyn did not describe a layered repair, even though he removed the scar.

Therefore, you should go with the benign excision code (11420-11426, Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia …). You will select the correct code by the length of the area removed.

From:Ob-Gyn Coding Alert


Question: A patient was taken to the operating room postdelivery to repair a vaginal sulcus tear and given an epidural. Can I bill for any additional service outside of the global package?

Michigan Subscriber

Answer: If the obstetrical physician performed the delivery, the repair is normally included in the global package.

If the ob/gyn performed the delivery but did not do an episiotomy repair post-delivery and the tear was found later, the repair may still be considered part of the global package.

If the physician who performed the delivery did an episiotomy repair that tore afterward (requiring a return to the operating room), the diagnosis is wound breakdown (674.2x, Disruption of perineal wound), and you can bill for a repair code that indicates genitalia.)

The choices are 12001-12007 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet] ), 12041-12047 (Layer closure of wounds of neck, hands, feet and/or external genitalia ) for intermediate repair, or 13131-13133 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet ) for complex repair.

The code you select would be appended with modifier -78 (Return to the operating room for a related procedure during the postoperative period).

If your ob/gyn did not perform the delivery, you can code the repair 59300 (Episiotomy or vaginal repair, by other than attending physician) with 674.2x (if the physician who performed the delivery had done a previous repair) or 665.44 (High vaginal laceration; postpartum condition or complication) for a newly treated tear so long as there was also no mention of a perineal tear.

If the perineal tear was noted in the operative report from delivery, then the diagnosis code would come from the 664.xx category (Trauma to perineum and vulva during delivery).

You can alter the tear Dx with vaginal peritoneal fistula

Related Topics