Ob-Gyn Coding Alert

Question: My ob-gyn provided the following documentation: Vaginal apex grasped, vertical incision over prolapse and epithelium dissected off of enterocele and cystocele, reduced using suture. Vaginal epithelium trimmed and closed with suture. Posterior fourchette grasped, incision made on posterior fourchette and vaginal epithelium excised. Sutured to perform high perineorrhaphy. Closed with suture. How should I report this? New York Subscriber Answer: First of all, you should recognize this is extremely minimal documentation. Encourage all physicians to describe more completely the procedures they perform. The risk: A payer may determine during an audit this documentation is insufficient to support the procedures performed. What you have here is: • an anterior repair (57240, Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele), • a vaginal enterocele repair (57268, Repair of enterocele, vaginal approach [separate procedure]) and, • a perineorrhaphy (56810, Perineoplasty, repair of perineum, nonobstetrical [separate procedure]). Before you apply [...]