Rectocele/Enterocele

[BABS37]

I'm not sure what to bill exactly with this. I'm thinking its just an enterocele?

...Vagina and perinum were prepped and draped in the sterile fashion. The posterior vaginal wall was retracted and Allis forceps on either side of the midline were incised vertically. In the avascular plane, the vaginal wall was separated from the rectocele, the upper portion of which formed the enterocele. Once the avascular plane was approximated in the midline with 0-vicryl horizontal mattress sutures to maintain reduction. The excess vaginal wall was then amputated and the vaginal mucosa was closed. The vaginal canal was somewhat foreshortened beforehand due to previous hysterectomy and it was slightly shorter even after completion of the rectocele repair but in order to maintain reduction of the enterocele, this was necessary...

I pulled up the surgery for an enterocele and my physician wants to bill for both... What CPT code do I use? Any help on this would be great! Thank you!

[martinni1974]

The documentation of this portion of the operative report would only support an vaginal enterocele repair. In addition, NCCI will not permit you to bill neither a posterior colporraphy (57250) or repair of rectocele (45560) had they been documented in addition to the enterocele repair.

There is not enough supporting documentation to support a rectocele repair period based on what is here. The one little blurb that states "the vaginal wall was separated from the rectocele" is not enough to support that procedure.

I would go with 57268 and that is all (based on the piece of documentation you listed).

Good Luck

[martinni1974]

Good catch by the way. You were right to begin with

[BABS37]

Thank you! His documentation isn't great on any of his surgeries to be honest. He's out of state but we are meeting at the end of the month so we can get his documentation guidelines in stone as he is missing out on lots of charges and addendums are hard to get. Thanks again on your help!