• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki need help!!!

Create Wiki
J

Jamie Dezenzo

True Blue
Messages
861
Location
Horseshoe Bend, AR
Best answers
0
Hi Ob/gyn coders:

patient asked that vaginal polyp be removed. We agreed to consider this. On vaginal exam, the patient had a significant tear of the vagina, which resulted in a large exophytic area of tissue. If I had excised the tissue only, she still would have had a mass bulging out of the vagina; it required me to excise the torn area and then make an incision-all on the left side-on the right side to reapproximate the tissue in a standard manner. This, however, took longer than expected-approx 20 minutes to complete.

I used 3-0 Vicryl to close the vaginal mucosa and the rebuild the perineal body. The perineal body was closed in a standard manner and subuticular was used to close the skin. Bipolar cautery to acquire hemostasis and 1% lidocaine was injected.

Complications: Large tear in vaginal wall had healed in the large exophytic tissue.

Path Sent: Came path Vaginal Polyp

I'm confused w/ this one....any thoughts???
THANKS!
Jamie
 
Hi Jamie,

I think you could use the 57135 - Excision of vaginal cyst or tumor with a modifier 22 for the additional work assuming that an extra 20 minutes is 25-50% more time than the procedure would normally take you to complete. I would suggest 623.7 - polyp of vagina and 623.4 - old laceration of vagina as the diagnosis codes based on your post.

Ruth Perkins, CPC, COBGC
 
You must log in or register to reply here.
Top