Ob-Gyn Coding Alert

Question: What’s the best way to code the vaginoperineoplasty portion of this procedure?

FINDINGS:

Shortened vaginal outlet secondary to vaginal scarring from second degree laceration after delivery and also 9 cm uterus.

DESCRIPTION OF PROCEDURE:

The patient was taken to the operating room where she was properly identified as herself. Appropriate timeout was performed. The patient was prepped and draped in the normal sterile fashion in a dorsal lithotomy position. The patient was examined under anesthesia and found to have a small anteverted uterus but also abnormally shortened vaginal outlet. The posterior fourchette of the vagina was incised via a diamond incision drawing from bilateral ends of the vulva down to the perineum and this was also extended internally into the vagina. Once this tissue was removed, the incision was closed anteriorly to posteriorly with good hemostasis noted throughout. There was Pitressin and lidocaine used during the procedure to help and control vaginal bleeding. Approximately 10 cc of the solution was used. Once the vagina was noted to be of normal caliber, the IUD was taken and placed into the uterus uneventfully. The patient was sounded to 9 cm and the strings were cut to approximately 3 cm in length. The speculum was removed from the vagina and again a second look at the perineum was noted to be hemostatic. At this point, the procedure was terminated.

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Answer: You should report 56800 (Plastic repair of introitus) because the physician is repairing the vaginal outlet. Also, your secondary code will be the intrauterine device (IUD) insertion, 58300 (Insertion of intrauterine device [IUD]).

Your diagnosis coding will include Z30.430 (Encounter for insertion of intrauterine contraceptive device). And since the repair was required due to a late effect of the perineal laceration, you will report O70.1 (Second degree perineal laceration during delivery), and a secondary diagnosis of O94 (Sequelae of complication of pregnancy, childbirth, and the puerperium). You may report an obstetric postpartum complication beyond the six-week postpartum period, according to the ICD-10 guidelines.