Ob-Gyn Coding Alert

Question: The patient underwent surgery for a vaginal cyst. She had an anterior vaginal cyst 3 to 3 1/2 cm in length removed. Over 90% was excised using the assistance of Allis clamp for counter­traction and the Bovie a vertical incision was then made 2 cm from the urethral meatus for total of 3 to 3-1/2 cm in length. During the incision, clear straw colored fluid was expelled from the vaginal cyst. The cyst wall was separated from the vaginal mucosa. There was no clear plane between the 2 tissues. But the cyst wall was over 90% excised. Excess vaginal tissue was also then excised. Quarter percent Marcaine was used in the subcutaneous vaginal mucosa. Cautery on the Bovie was also used for hemostasis. Using 2-0 Vicryl on SH needle the deep vaginal tissue was reapproximated using vertical mattress both for better reapproximation and for hemostasis. The vaginal mucosa was then closed also using 2-0 Vicryl in a continuous fashion. What CPT^® code should I use for this?

South Carolina Subscriber

Answer: You should report 57135 (Excision of vaginal cyst or tumor) for this procedure because the ob-gyn removed a vaginal cyst. You should consider the repair of the tissues and the draining of the cyst as included.