How would you code this?-congenital defect

mjewett

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We have a patient who had a congenital defect, when she was a child she had a vagina constructed out of bowel. Now she is 28 and is having trouble with the "neo vagina" per my doctors records the symptoms are presenting like colitis. My doctor performed an endoscopic exam with bx. of the "neo vagina" A pediatric endoscope was inserted "vaginally" the tissue rec'd was bowel tissue. The pediatric endoscope was withdrawn and then inserted into rectum to perform a Flexible Sigmoidoscopy. My first thought was to code a hysteroscopy with bx. and Flex Sig with bx. But a hysterscope was not used and there is no vaginal tissue only bowel. I don't see any unlisted endoscopy codes either. Anyone have a suggestion?

Thanks
Melissa Jewett, CPC
 

mjewett

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Thank you- I spoke to another coder and she too suggested not to get tripped up over the fact that the vagina was constructed out of bowel, and to code it site specific. I Will code Colposcopy w/ bx and flex sig.
 
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