Ob-Gyn Coding Alert

Question: One of our ob-gyns performed an examination under anesthesia, exploratory laparotomy with left salpingo-oophorectomy and vaginal repair of the vaginal cuff. He also performed an excision of inflammatory material from the vaginal cuff, which was thought to include some fimbria caught in the area. Should I use unlisted-procedure code 58999 for the vaginal repair of the vaginal cuff? What diagnosis code should I use? The ob-gyn listed the diagnosis in the op note as -granulation into the vaginal cuff with an opening and tubal fimbria prolapsing through.- 


Arkansas Subscriber


Answer: First, you should not report the exam under anesthesia or exploratory laparotomy. These procedures are standards of surgical technique and therefore not separately reimbursable. 

For the repair of the vaginal cuff, you will be confined to using 58999 (Unlisted procedure, female genital system [nonobstetrical]). Be sure to submit your op report along with a cover letter that explains in simple, straightforward language exactly what your ob-gyn did. Remember to explicitly reference the nearest equivalent listed procedure in your explanatory note.

As a diagnosis, you should use 616.8 (Other specified inflammatory diseases of cervix, vagina, and vulva) -- if this procedure is happening quite some time following the original surgery. If the ob-gyn indicates that this involves disruption of the internal sutures, you can use 998.31 (Other complications of procedures, not elsewhere classified; disruption of internal operation wound).

Caution: Stay away from the mechanical complication code (996.65, Infection and inflammatory reaction due to internal prosthetic device, implant, and graft; due to other genitourinary device, implant and graft) because this diagnosis, unfortunately, does not fit this scenario.

Also, be sure to avoid diagnosis code 701.5 (Other abnormal granulation tissue) because you would use this for granulation tissue on the skin, which would also not apply to this situation.