Ob-Gyn Coding Alert

You Be the Coder:

When Injury Is Ob, Use This Code

Question: Our ob-gyn repaired a vaginal laceration for a patient who is two weeks postpartum and came in bleeding profusely. What would be the most appropriate code to use for this?

New Jersey Subscriber

Answer: The only code you can use is 59899 (Unlisted procedure, maternity care and delivery). You cannot use another code, because this was not a non-ob injury to the vagina. Skin repair codes do not apply, because it was a laceration to the vaginal canal-- not the perineum or vulvar area.

Note: You should offer a detailed description of the procedure the ob-gyn performed, and you will want to compare the work to an existing CPT® code. In this case, you may want to compare the work to 57200 (Colporrhaphy, suture of injury of vagina [nonobstetrical]). If the physician does the repair in the operating room, do not forget to add 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) Don’t forget documentation of medical necessity to back up the decision to perform the procedure, as well as the time, effort, and equipment the ob-gyn used.