Wiki partial vaginal vault excision

[Babsss]

I am stuck on this one. First vaginal approach. The physician is unsure if the area is a fistula- like tract in the area of the anterior portion of the vaginal just inside the introitus. This area appeared to have some erythema that could have been consistent with granulation tissue. That area of the vaginal vault was excised using an elliptical incision just inside the introitus ad entering into the vaginal vault approximately 2cm. This area was excised using metzenbaum scissors incorporating the area of suspected fistulous tract or granulation tissue. I have looked at 57106 for Vaginectomy, partial, but think it may be over coding when I read the full description. I have also looked at 57135, but is not a cyst or tumor. Any help is appreciated. I may be just overworking it. Thanks in advanced.

 

[tmerickson]

Can you give me more information? What was the surgeon's post op diagnosis? How did he close after the "defect" was removed? Did he have to do a tissue transfer, like a flap or just a normal closure?

 

[csperoni]

More information would be helpful, but with the information provided, I would lean toward 57106. While that is typically a more extensive procedure, in your case, you may fall at the minimal end of "partial". If 57106 really seems like overcoding, then 57106-52
The other option may be to use unlisted, which I avoid if possible.