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Perineal defect, nonhealing, obstetrical complication

CC Posted Thu 04th of June, 2020 16:42:22 PM
I'm having trouble finding the correct CPT code for: 1. Resection of scar and granulation tissue on the perineum. 2. Marsupialization of the vaginal wall for drainage of abscess. POSTOPERATIVE DIAGNOSES: 1. Perineal defect, nonhealing, obstetrical complication. (delivery 6 months ago) 2. Small vaginal abscess. The perineal defect was friable with granulation tissues seen. With deeper palpation and with probing with a hemostat, we were able to express a small amount of purulent material. With the rectovaginal exam, there was no evidence of any purulent material through the rectum, and there was no obvious communication with the hemostat into the rectum. There was a thin area noted extending into the distal vagina where the likely accumulation of the abscess was. The initial procedure was for using the hemostat once again through the perineal abscess, again with the finger in the rectum to ensure no injury, a thin area was noted along the distal vaginal wall. This was infiltrated with Marcaine with epinephrine and then incised creating a 0.5 cm defect. The edges along here were marsupialized with interrupted 2-0 Vicryl suture, and the area was copiously irrigated with antibiotic solution. No other abscess or purulent material was noted with the multiple irrigations. At this point, attention was then turned down towards the actual perineal defect itself. The area was infiltrated with epinephrine once again, and a small 2-3 mm resection around the area was undertaken with a knife and Metzenbaum scissors for removal of the granulation tissue. Once all the granulation tissue was removed, the area was irrigated once again, again with free flow of fluid through the defect from above. Then using 2-0 Vicryl suture in a 3-layer closure to reapproximate the perineal defect.
SuperCoder Answered Fri 05th of June, 2020 04:44:16 AM


Thank you for your question. However, AAE does not provide coding for operative reports and chart notes.

SuperCoder offers SuperCoding on Demand (SOD) ( for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail for more information.


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