Ob-Gyn Coding Alert

Reader Questions:

Research Your Ob-Gyn's Report for Rectocele/Enterocele

Question: If the ob-gyn states he did a posterior/anterior repair because of vaginal vault prolapse, would that be the same as 57260? The ob-gyn did not document a cystocele or rectocele, but the ob-gyn encountered enterocele.

Florida Subscriber

Answer: No, you should not report 57260 (Combined anteroposterior colporrhaphy). An ob-gyn would not perform an anterior repair unless she was dealing with a cystocele. An ob-gyn can do a posterior repair for either a rectocele or an enterocele, however.
 
If he did only an enterocele repair, use the enterocele repair codes (57268 (Repair of enterocele, vaginal approach [separate procedure]) or 57270 (Repair of enterocele, abdominal approach [separate procedure]).
 
Note: In order to report 57260, you have to give a diagnosis of both cystocele (618.01, Cystocele, midline; or 618.02, Cystocele, lateral) and rectocele (618.04) to support doing the procedure. Speak to your ob-gyn regarding his diagnosis.

 - The answers for Reader Questions and You Be the Coder were provided by Melanie Witt, RN, CPC, MA, an ob-gyn coding expert based in Guadalupita, N.M.

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