If anyone can offer a suggestion on this coding scenario I would greatly appreciate it.
Patient born with cloaca malformation presents to OR where surgeon performs colostomy with mucous fistula and drainage of hydrocolpos with creation of tube vaginostomy. I am having trouble choosing a procedure code for the tube vaginostomy w/drainage of hydrocolpos.
"On entering the abdomen, there was a large, distended, inflamed mass which was carefully dissected free from surrounding tissue and identified as the distended and inflamed vagina. A 3-0 vicryl purse-string suture was placed in the apex of the vagina and an 18-gauge needle was introduced into the vagina and fluid was evacuated. The needle was removed and the vagina entered at the needle stick site with bovie cautery. A copious amount of fluid drained and the vagina became decompressed. We inspected internally and did not identify a vaginal septum.
A 12-French Malecot drain was brought onto the field and placed through the previously created vaginostomy. The pursestring suture was tied down to secure the Malecot within the vagina. A site was selected in the right lower quadrant of the abdomen and a skin incision was made and the Malecot tube was brought through the skin incision. A Stamm technique was used to secure the vagina to the anterior abdominal wall using interrupted 4-0 vicryl sutures."
Patient born with cloaca malformation presents to OR where surgeon performs colostomy with mucous fistula and drainage of hydrocolpos with creation of tube vaginostomy. I am having trouble choosing a procedure code for the tube vaginostomy w/drainage of hydrocolpos.
"On entering the abdomen, there was a large, distended, inflamed mass which was carefully dissected free from surrounding tissue and identified as the distended and inflamed vagina. A 3-0 vicryl purse-string suture was placed in the apex of the vagina and an 18-gauge needle was introduced into the vagina and fluid was evacuated. The needle was removed and the vagina entered at the needle stick site with bovie cautery. A copious amount of fluid drained and the vagina became decompressed. We inspected internally and did not identify a vaginal septum.
A 12-French Malecot drain was brought onto the field and placed through the previously created vaginostomy. The pursestring suture was tied down to secure the Malecot within the vagina. A site was selected in the right lower quadrant of the abdomen and a skin incision was made and the Malecot tube was brought through the skin incision. A Stamm technique was used to secure the vagina to the anterior abdominal wall using interrupted 4-0 vicryl sutures."