Ob-Gyn Coding Alert

Question: Patient is two weeks status post anterior colporrhaphy with repair of enterocele. Upon vaginal exam, her anterior repair had opened up in multiple areas. Our doctor, who did not perform the original surgery, did the vaginal repair. He notes the vaginal laceration was anterior, approx. 5 cm in length and along the previous site of the anterior colporrhaphy. The apex of the laceration was identified and 4-0 Vicryl was used in running locked fashion. Two sutures were utilized. Vagina packed hemostasis noted. Would this qualify for 13132-78? If not, please help with correct CPT® for this procedure.

Washington Subscriber

Answer:  This description does not support a complex repair of the genitalia so the code 13132 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm) would not be correct. Instead, he performed a repair of a vaginal laceration and the best code for this would be 57200 (Colporrhaphy, suture of injury of vagina [nonobstetrical]). 

If your ob-gyn is not part of the practice that did the original surgery, you would not use a modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period).