Ann Posted Thu 16th of February, 2017 20:37:33 PM
Would this be unlisted code? 58999 and what would be a comparable code?
With patient in the dorsal lithotomy position and following adequate anesthesia, prepping and draping, the anterior aspect of the cervix was grasped with a clamp and held posteriorly. The vaginal mucosa was entered anteriorly, 2 mm above the reflection and the incision was extended in a circumferential manner from 10 - 2:00. Using sharp and blunt dissection the bladder was separated from the uterus and retracted forward. Using a dilator through the cervix, the defect was easily identified. Using cutting cautery the defect was entered (old blood and purulent looking material extruded upon entry) and using sharp dissection was excised. The defect was then closed in 2 layers (a dilator was passed into the uterus to make sure the posterior aspect of the cervix was not included in the closure) using 2-0 vicryl and the dilator in the cervix demonstrated that the defect was corrected. Hemostasis was confirmed and the space was irrigated before the vaginal mucosa was closed with 2-0 vicryl.
Hemostasis was again confirmed and the bladder was catherized for 200cc of clear yellow urine
SuperCoder Answered Fri 17th of February, 2017 02:53:53 AM
Greetings from SuperCoder.com!
There is no specific code for excision of Cesarean scar defect. So you should report unlisted code - 58999 (Unlisted procedure, female genital system (nonobstetrical)). Please be sure to attach documentation to support the code. Code 57135 (Excision of vaginal cyst or tumor) may be used as a comparable code.
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