Bilateral vaginal (sulci) tears

SHIBA425

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Can anyone provide any insight????? Below is the operative report. This patient delived vaginal and was found to have bilateral vagianl (sulci) tears.

It is my understanding that this would be included in the vaginal delivery or am I way off base? IF it is separately billable what CPT code would be appropriate? Most of the vagianl repair codes are (nonobstetrical).

:confused:

OPERATIVE PROCEDURE: Repair of bilateral vaginal lacerations.

COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 75.
FLUIDS: 700 of lactated Ringer's.
URINE OUTPUT: Not measured.

GROSS FINDINGS AND TECHNIQUES

INDICATIONS: This is a 32-year-old woman who delivered vaginally. She had vaginal lacerations of both lateral walls, three quarters of the way up of the vagina. Attempt was made to visualize and repair this in the delivery room but we could not see the apex of either of the lacerations.

FINDINGS: She did have bilateral sulci tears on her left side, actually all the
way up to the cervix and on the right side three-quarters of the way up the
vaginal wall. With this also there was a hymenal ring tear and then a
superficial first degree laceration on the left side of the perineum.

PROCEDURE: The patient was taken to the operating room where spinal anesthesia was obtained and found to be adequate. She had been prepared and draped in the dorsal lithotomy position. Exam was done. Using 3-0 Vicryl, I did a running lock suture to repair the vaginal wall lacerations on both sides joining the hymenal ring and then did a crown stitch. I then repaired the first degree skin laceration on the left side of the perineum also with 3-0 Vicryl. She tolerated all this well. She was taken awake to the recovery room in good condition.


thank you for any assistance you can offer.
jlf
 
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