How do I code "revision of vaginal suture line" ?

dcrossman

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My provider did a "revision of vaginal suture line" for a patient that presented to the ER for vaginal hemorrhage.

I'm not sure how to code this because the original surgery was done by a different doctor in a different practice. I believe I will need to use modifier 78 for an unplanned return to the OR, but I'm not sure if the diagnosis codes and CPT code I picked is correct.

I chose dx: 998.31 Discruption of internal operation surgical wound (disruption or dehiscence of closure of: fascia, superficial or muscular; internal organ; muscle or muscle flap; ribs or rib cage; skull or craniostomy; sternum or sternotomy; tendon or ligament; Deep distruption or dehiscense of operation wound NOS EXCLUDES: complactions of internal anastomosis of: gastrointestinal tract (997.49) urinary tract (997.5).

The CPT code I'm not sure of either: I found 57200 Colporrhaphy, suture of injury of vagina (nonobstetrical) and I would attach modifier 78, but I'm second guessing myself on all these.

Can anyone offer me what you would do? I've enclosed the surgical note below:

Obsteric & Gynecology Operative Report​

Date of Operation: 7/21/2012
Preoperative Diagnosis: Vaginal hemorrhage
Postoperative Diagnosis: Vaginal hemorrhage
Procedure: Revision of vaginal suture line

Findings: There were multiple site of bleeding from the previous incision line from the total vagnial hysterectomy and anterior and posterieor repair completed Tuesday, July 17.

Description of Procedure: After general anesthesia was obtained, the patient was placed in the lithomoy position and the perineum prepped and drapped in the usual sterile fasion. The patient's peripad, Chux and vaginal clots constituted approximately 800 mL of blood loss. A posterior weighted speculum was placed and the vaginal canal carefully inspected. Areas of oozing were identified. Approximately 14 figure-of-eight sutures of 0 Vicryl and 2-0 Vicryl were placed in order to secure homostasis. This was verified with several minutes of observation. The procedure was then terminated. Vaginal instruments were removed and the patient returned to supine position. She was awakened and taken to the recovery room in a stable and responsive condition, having tolerated the procedure well. Estimated blood loss was minimal.
 

preserene

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I feel you are right with both the codes and the modifier There was definitely an examination under anesthesia but it gets covered with the colporraphy code.
 
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