Ob-Gyn Coding Alert

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.