Ob-Gyn Coding Alert

You Be the Coder:

Sulcus Tear Repair

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.

Question: How does a physician bill for a deep sulcus tear repair when she was called in following a midwife delivery? This is a midwife obstetrics patient who was seen prenatally by the midwife and delivered by the midwife.

Heather Lurie, MD
Mercy Ob/Gyn, Bronx, N.Y

Answer: In an episiotomy, the physician makes a pudendal incision to widen the vulvar opening and permit easier passage of the fetus. Sometimes the babys head causes tears beyond the incision, and sometimes the tears result from delivery without episiotomy. Normally, episiotomy repair, including the repair of lacerations, would be part of the global obstetric package.

In this case, however, a person different from the delivering professional is called in to make the repair, and this can be coded separately. The code for this would be 59300 (episiotomy or vaginal repair, by other than attending physician). You will note that CPT does not differentiate between types of vaginal repair. A sulcus is simply a groove or furrow, and a deep sulcus tear does not describe the severity of the laceration in any detail.

Most lacerations are described as being first degree (involving the fourchette, perineal skin and vaginal mucous membrane), second degree (which extends into the muscles of the perineal body, but does not extend into the anal sphincter), third degree (which extends well into the sphincter ani) or fourth degree (which includes tearing into the rectal mucosa). If the physician has documented significant work in repairing the laceration, that is, a third- or fourth-degree laceration repair, you might elect to add a modifier 22 (unusual procedural services) to code 59300.

As is normally the case, the documentation must be submitted with the claim to avoid initial denial.