Ob-Gyn Coding Alert

Question: I-m looking for a CPT code for the following procedure. The indications are a sessile polyp cone biopsy one month prior, and the patient is experiencing vaginal bleeding. The ob-gyn performed an exam anesthesia and placed a figure-of-eight suture in the posterior lip of the cervix. What should I report?

California Subscriber

 Answer: If no injury caused the bleeding, report 58999 (Unlisted procedure, female genital system [nonobstetrical]). On the other hand, if the patient had an actual injury, you might consider 57200 (Colporrhaphy, suture of injury of vagina [nonobstetrical]).

Your diagnosis will depend on the stated reason for the vaginal bleeding as a complication of the procedure.  For instance, you might use hemorrhage following the procedure (998.11), a fistula or wound dehiscence (998.31) or a persistent fistula (998.6), so be sure to check the documentation.

Good news: Because the patient underwent a biopsy a month ago, you are likely outside of the biopsy's global period, so you do not need modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period).