Wiki Excision of Vaginal Granulation Tissue after a vaginoplasty (male to female)

tloeb

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I have just acquired coding for a Gender Care clinic at my health system. The provider performs the an exicision of vaginal granulation tissue often long after the global post op period. Would code 58999 be used comparing to 11420-11426 codes or 57100/57105 when performed with scissors and curette? 3 separate examples are below:

1-I first performed a speculum exam and noted extensive exophytic granulation tissue throughout the vaginal cavity, including the apex. I used a combination of scisssor and curette to excise the granulation tissue to its base. Once this was achieved, I used the bovie to control any small areas of bleeding and applied bacitracin ointment to the lining and left a vaginal pack in place until the end of the case to control any oozing. This was removed prior to the end of the case. **58999 compared to 11420 as no measurement or 57105?

2-Speculum exam - there were several areas of granulation tissue that I excised with scissors and curette. Otherwise, lining was healing well without any other abnormalities. The granulation tissue has improved compared to last exam in Jan 2023. **My thought is 58999 compared to 11420 as no measurement or 57105?

3-"There is an area of granulation tissue at the introitus. After confirming allergies, I injected 3 mls 2 % lidocaine into the tissue. I then sharply excised the granulation tissue down to its based and then held pressure with some dry gauze." **My thought is 11420 seems to be the better code selection for this one as the location is the introitus.?

Also, would the better DX code be N99.2 or N76.89 or L92.8.
Thank you for any help!
 
With 58999 (or any unlisted code), it is often helpful to have the provider input. Unlisted codes are just that - don't have a code, so you use unlisted and tell the insurance company which code is closest, or represents a similar amount of work. If you are unable to determine that from the note, your provider is the best person to provide that guidance.
That aside, I'll offer some opinions on your examples. For extensive INTERNAL granulation tissue, I would consider comparison to the work of debridement rather than either 11420 or 57105 (11042-11046). When you are using exact CPT codes with a size specified, that size must be documented. When you are saying "this procedure is the same/similar amount of work as that procedure", there is no requirement for size. That being said, your example 1 seems rather extensive and I would advise my provider moving forward better documentation (sq cm, or actual size, or something that helps explain the work) is helpful in getting accurate reimbursement. I would lean toward debridement comparison for this one as it indicates "throughout the vaginal cavity."
Example 2 - again documentation vague, but seems less extensive than #1. "Several areas" - 3 or 6. Size of the areas?? For that I would lean toward 57105.
Example 3 - Since this seems to be more the external genitalia, I would use 11420-11426. Again, advising my provider about documentation

Diagnosis -
N99.2 states adhesions of the vagina. I would not use that for granulation tissue.
L92.8 other granulomatous disorders of the skin and subcutaneous tissue. Skin codes are not the best choice for internal vaginal granulation tissue.
N76.89 while rather generic would be your best choice in my opinion.
 
With 58999 (or any unlisted code), it is often helpful to have the provider input. Unlisted codes are just that - don't have a code, so you use unlisted and tell the insurance company which code is closest, or represents a similar amount of work. If you are unable to determine that from the note, your provider is the best person to provide that guidance.
That aside, I'll offer some opinions on your examples. For extensive INTERNAL granulation tissue, I would consider comparison to the work of debridement rather than either 11420 or 57105 (11042-11046). When you are using exact CPT codes with a size specified, that size must be documented. When you are saying "this procedure is the same/similar amount of work as that procedure", there is no requirement for size. That being said, your example 1 seems rather extensive and I would advise my provider moving forward better documentation (sq cm, or actual size, or something that helps explain the work) is helpful in getting accurate reimbursement. I would lean toward debridement comparison for this one as it indicates "throughout the vaginal cavity."
Example 2 - again documentation vague, but seems less extensive than #1. "Several areas" - 3 or 6. Size of the areas?? For that I would lean toward 57105.
Example 3 - Since this seems to be more the external genitalia, I would use 11420-11426. Again, advising my provider about documentation

Diagnosis -
N99.2 states adhesions of the vagina. I would not use that for granulation tissue.
L92.8 other granulomatous disorders of the skin and subcutaneous tissue. Skin codes are not the best choice for internal vaginal granulation tissue.
N76.89 while rather generic would be your best choice in my opinion.
Thank you @csperoni - I was hoping to get a response from you :) as you are always so articulate and helpful, appreciate you!
 
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