Hello OB/GYN Group,
I need your assistance please:
Pt presents for follow up of vaginal pain. Patient has had 3-4 years of constant vaginal pain that has worsened over the last year. Describes as a dull, throbbing, constant fullness, no radiation, no provoking or relieving factors. Denies using any perfumed soaps, douching, or other irritating agents in the vagina.
Has trialed the following:
- >6 months of Premarin (refilled prescription ~5 times, per her husband)
- Monistat,
- OTC Emuaid (antifungal).
Reports continued intolerance to vaginal intercourse 2/2 pain. At last visit patient underwent pelvic exam with lidocaine injection at area of maximum tenderness. Patient reports pain was greatly improved after injection but soon returned after the lidocaine wore off. Additionally, she was started on Gabapentin 300 BID and was given Rx for EMLA cream. Patient reports no improvement in symptoms with the Gabapentin and feel that the EMLA cream and other over the counter numbing creams she has tried provide only very brief periods of relief.
Genitourinary:
Genitourinary Comments: No vulvar tenderness, no visible lesions, erythema, excoriations, or other tissue abnormalities. Again visualized stage II anterior and posterior pelvic prolapse. Moderate tenderness at 11 o'clock Position on vestibule. Area of maximum tenderness again at 4 o'clock on left aspect of vestibule using q-tip. Small sub centimeter gland like opening again visualized at area of maximum tenderness. No apparent drainage, erythema, or discharge. No midline, or suburethral tenderness. 2% lidocaine (10 ml) was injected under and around gland like opening. Silver nitrate was then used to chemically cauterize the tissue opening and the small bleeding from the injection site.
ASSESSMENT & PLAN:
#1 Vaginal pain (Primary)
Overview:
Failed >6 months Premarin as well as trials of antifungals.
Exam 12/15: small glandular-appearing opening at left aspect of vestibule, around 4:00 position, with exquisite pinpoint tenderness. Significantly improved with injection of 1% lidocaine.
Meets criteria for localized vulvar pain syndrome (not ICD diagnosis).
- Trial of Gabapentin 300mg QD x7 days followed by BID dosing
- Topical Nifedipine from compounding pharmacy
2/8/23: No improvement of pain with Gabapentin use. Minimal improvement with EMLA cream and OTC numbing agents. Glandular opening at 4 o'clock position again visualized. Significant improvement after 2% lidocaine injection. Glandular area and bleeding from injection site cauterized with silver nitrate.
Assessment & Plan:
As she has failed topical estrogen and antifungals, Gabapentin, lidocaine injections, would recommend EUA with possible partial vestibulectomy in the area of concern.
Will present patient in next pre-op conference for further consideration. Patient may need referral to specialist for further evaluation. Plan to follow up in 2 weeks for definitive surgical vs referral planning.. In the meantime, ok to continue EMLA cream and Gabapentin for symptom relief.
Will follow up in 2 weeks for further surgical vs referral planning.
Dose Freq Start End
lidocaine 2 % injection 100 mg 100 mg Once 2/8/2023
Route: Subcutaneous
Is there a CPT code that would fit this procedure, I was thinking to bill the Unlisted E & M code but wanted to query what code would be the closet to what was done. Thank you for your time and assistance!
I need your assistance please:
Pt presents for follow up of vaginal pain. Patient has had 3-4 years of constant vaginal pain that has worsened over the last year. Describes as a dull, throbbing, constant fullness, no radiation, no provoking or relieving factors. Denies using any perfumed soaps, douching, or other irritating agents in the vagina.
Has trialed the following:
- >6 months of Premarin (refilled prescription ~5 times, per her husband)
- Monistat,
- OTC Emuaid (antifungal).
Reports continued intolerance to vaginal intercourse 2/2 pain. At last visit patient underwent pelvic exam with lidocaine injection at area of maximum tenderness. Patient reports pain was greatly improved after injection but soon returned after the lidocaine wore off. Additionally, she was started on Gabapentin 300 BID and was given Rx for EMLA cream. Patient reports no improvement in symptoms with the Gabapentin and feel that the EMLA cream and other over the counter numbing creams she has tried provide only very brief periods of relief.
Genitourinary:
Genitourinary Comments: No vulvar tenderness, no visible lesions, erythema, excoriations, or other tissue abnormalities. Again visualized stage II anterior and posterior pelvic prolapse. Moderate tenderness at 11 o'clock Position on vestibule. Area of maximum tenderness again at 4 o'clock on left aspect of vestibule using q-tip. Small sub centimeter gland like opening again visualized at area of maximum tenderness. No apparent drainage, erythema, or discharge. No midline, or suburethral tenderness. 2% lidocaine (10 ml) was injected under and around gland like opening. Silver nitrate was then used to chemically cauterize the tissue opening and the small bleeding from the injection site.
ASSESSMENT & PLAN:
#1 Vaginal pain (Primary)
Overview:
Failed >6 months Premarin as well as trials of antifungals.
Exam 12/15: small glandular-appearing opening at left aspect of vestibule, around 4:00 position, with exquisite pinpoint tenderness. Significantly improved with injection of 1% lidocaine.
Meets criteria for localized vulvar pain syndrome (not ICD diagnosis).
- Trial of Gabapentin 300mg QD x7 days followed by BID dosing
- Topical Nifedipine from compounding pharmacy
2/8/23: No improvement of pain with Gabapentin use. Minimal improvement with EMLA cream and OTC numbing agents. Glandular opening at 4 o'clock position again visualized. Significant improvement after 2% lidocaine injection. Glandular area and bleeding from injection site cauterized with silver nitrate.
Assessment & Plan:
As she has failed topical estrogen and antifungals, Gabapentin, lidocaine injections, would recommend EUA with possible partial vestibulectomy in the area of concern.
Will present patient in next pre-op conference for further consideration. Patient may need referral to specialist for further evaluation. Plan to follow up in 2 weeks for definitive surgical vs referral planning.. In the meantime, ok to continue EMLA cream and Gabapentin for symptom relief.
Will follow up in 2 weeks for further surgical vs referral planning.
Dose Freq Start End
lidocaine 2 % injection 100 mg 100 mg Once 2/8/2023
Route: Subcutaneous
Is there a CPT code that would fit this procedure, I was thinking to bill the Unlisted E & M code but wanted to query what code would be the closet to what was done. Thank you for your time and assistance!