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Repair vaginal tear by attending Dr as separate procedure

lorijmcc

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Hi- Any ideas on how to code for repair of vaginal sulcus tear by the attending/delivery Dr? 59300 indicates repair of vaginal repair;by other than attending, so I cannot use that code.

The pt initially had a vaginal delivery. "Heavy bleeding was noted immediately after delivery of the placenta. No episiotomy, no shoulder dystocia noted. Exam of the vaginal vault revealed a Rt labial laceration & a very large, deep vaginal sulcus tear extending nearly to the fornix. Dr was unable to visualize the apex of tear well. Bleeding was brisk and decision was made to pack the vagina, call for type & crossed packed cells and move quickly to the OR to complete the repair."

Op rpt for repair of right vaginal sulcus tear indicates:
"The two large sponges were removed with ring forceps and the nurses
visualized this. A Foley catheter was inserted into the urethra and the
bladder drained of clear, yellow urine. Two lateral retractors were
introduced into the vagina and the apex of the laceration was able to be
identified. It was closed with a running locking suture of #1-0 Vicryl.
Vaginal area near the introitus was identified and reapproximated using a
running locking suture of #3-0 Vicryl. The dead space was closed with
running locking suture of #1-0 Vicryl. There were several tear through
spots from the #1-0 Vicryl near the introitus of the sulcus tear, and
these were reapproximated with running suture of #3-0 Vicryl. The tear in
the right labia was opened during this process and was reapproximated with
a running locking suture of #3-0 Vicryl. There was a small periurethral
laceration on the left side which was closed with figure-of-eight suture
of #3-0 Vicryl. The perineal body was closed with a running suture of
#3-0 Vicryl and perineal skin, which was minimally involved, was closed
with a running suture of #3-0 Vicryl. Hemostasis was excellent. The apex
was reexamined and was hemostatic. The Foley catheter continued to drain
clear yellow urine. Adipose tissue was no longer visible, closed under
the vaginal mucosa. The vagina was packed with two rolls tied together of
one inch untreated gauze and was hemostatic. The patient had been given
Vancomycin throughout the labor process, was given Gentamicin 80 mg IV and
Flagyl 500 mg IV during the procedure."

Any help would be appreciated!
 

preserene

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I feel that you can append mod -22 , along with her service whether global or whatever. It is more than an /or an extended tear of the episiotomy wound and the episiotomy is included in the vaginal delivery. But supportive diagnostic code shoud be assigned like 664.14, depending on the hemorrhage factor, 664.x ,depending upon the degree of laceration as documented by the provider.
I think it could help to some extent.
 
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