"Repair" of laceration months after delivery.

[cgarciamck87@gmail.com]

I previously asked a similar question regarding laceration repairs but this one is under a different circumstance.

This patient had a vaginal delivery several months ago and at the time had an episiotomy and repair (done with a different physician). She is coming in due to issues with this repair. Note stated "exam show tight posterior fourchette adhesion likely related to healing post delivery. Discussed releasing the adhesion by simple procedure in office with local anesthetic". Would the cpt in this case be 56441?

 

[nielynco]

I previously asked a similar question regarding laceration repairs but this one is under a different circumstance.

This patient had a vaginal delivery several months ago and at the time had an episiotomy and repair (done with a different physician). She is coming in due to issues with this repair. Note stated "exam show tight posterior fourchette adhesion likely related to healing post delivery. Discussed releasing the adhesion by simple procedure in office with local anesthetic". Would the cpt in this case be 56441?

As the posterior fourchette is where the labia minora meet, you could technically report this code. But keep in mind that the assignment of relative value units for this code was based on something more than a quick release of a single adhesion (the code was intended to describe adhesions that bind the inner and outer labia together). In fact, the typical time assigned to this code by the CPT RBRVS committee is 1 hour 7 minutes (excluding anesthesia time). The payer may or may not want to see the documentation to determine payment.