Wiki Pelvic Exam under Anesthesia, Vaginal tissue biopsy, vaginal abscess debridement and vaginal packing

[dmarshall]

Hello OB/GYN Group,

I am reaching out for CPT coding assistance on this procedure please:

Procedure Details:
The patient was taken to Operating Room, identified as XXXX and the procedure verified. A Time Out was held and the above information confirmed. General anesthesia was administered without difficulty. She was placed in dorsal lithotomy position in Allen type stirrups. Patient was prepped and draped in the normal sterile fashion. Next, a weighted speculum was placed in the vagina. The anterior wall of the the vagina was noted to have a walled off opening of circumferential hardened vaginal tissue that tracked cephalad in multiple directions. Necrotic walled off abscesses about 1.5 cm in depth tracted to the 9:00, 11:00, and 3:00 direction. These areas were opened up and gently debrided with a spoon curette as not to perforate into the rectum or bladder. These areas were copiously irrigated repeatedly to free necrotic tissue from area. Vascularized tissue was noted after debridment. A vaginal tissue biopsy was obtained from the 6:00 to 7:00 area and sent to pathology, hemostasis was observed. The vaginal cuff/apex at the vagina was felt to be intact. All vaginal tracts were felt to be intact without noticeable fistula formation too bladder or rectum. A rectal exam was performed and there was no defect or connection between vagina and rectum. Gloves were changed. Iodoform packing was placed in the vagina. A Foley was placed at the completion of the case secondary to vaginal packing in place, urine clear. Vaginal packing to remain in place for 2 to 3 days, and will reacess if additional packing will be need after removal. After the procedure, all instruments were removed from the vagina. The patient tolerated the procedure well. All counts were correct. The patient was taken from the operating room in stable condition after she was cleaned.

Diagnosis:
A. Vagina, biopsy:
Invasive squamous cell carcinoma, keratinizing type.
p16 immunostain positive.
B. Vaginal contents, removal:
Peripheral blood elements only


I was looking at CPT code 57010. Would you advise. Thank you.

Dorine Marshall,CPC,COBGC
Tulsa,Ok

 

[csperoni]

57010 Colpotomy; with drainage of pelvic abscess
In this procedure, the provider incises the vaginal wall to drain an abscess in the pelvic cavity.
Clinical Responsibility: The provider may administer local, regional, or general anesthesia. The provider places the patient in the dorsal lithotomy position and inserts a speculum to view the cervix, which he grasps with a toothed instrument called a tenaculum. This is done to expose the back of the vagina, clinically referred to as the posterior vaginal fornix. After applying an antiseptic solution, the provider makes an incision through the vaginal wall. He punctures the abscess with a long hemostat, and the hemostat may be spread apart to enlarge the opening and allow the abscess to drain. He explores the cavity and may insert a drain to promote continued drainage. Once he successfully drains the abscess, the provider closes the incision with sutures.

I'm not interpreting the procedure done as cutting through the vaginal wall to access and drain a pelvic abscess.
Other considerations I ruled out:
11006 - not external genitalia so out for me
11042 - not skin, so out for me
I looked through all the vagina codes and nothing seemed accurate. You will likely be left with unlisted. Possible comparison codes (I would ask the clinician to weigh in) would be 57010, 57023, 57106.

 

[dmarshall]

57010 Colpotomy; with drainage of pelvic abscess
In this procedure, the provider incises the vaginal wall to drain an abscess in the pelvic cavity.
Clinical Responsibility: The provider may administer local, regional, or general anesthesia. The provider places the patient in the dorsal lithotomy position and inserts a speculum to view the cervix, which he grasps with a toothed instrument called a tenaculum. This is done to expose the back of the vagina, clinically referred to as the posterior vaginal fornix. After applying an antiseptic solution, the provider makes an incision through the vaginal wall. He punctures the abscess with a long hemostat, and the hemostat may be spread apart to enlarge the opening and allow the abscess to drain. He explores the cavity and may insert a drain to promote continued drainage. Once he successfully drains the abscess, the provider closes the incision with sutures.

I'm not interpreting the procedure done as cutting through the vaginal wall to access and drain a pelvic abscess.
Other considerations I ruled out:
11006 - not external genitalia so out for me
11042 - not skin, so out for me
I looked through all the vagina codes and nothing seemed accurate. You will likely be left with unlisted. Possible comparison codes (I would ask the clinician to weigh in) would be 57010, 57023, 57106.

Hello Ms Christine,
Thank you so much for your feedback, much appreciated, I am in agreement to use the unlisted code with your comparison codes that you listed, and I will query our Attending as well so that we can capture a code that fits close to this procedure. Again, thank you for taking the time to research the best possible code selection for this procedure.