Wiki Revision of Introitus for Vaginal Atresia

[dmarshall]

Hello Group,

Please see procedure in detail below:

The patient was taken to Operating Room, identified 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. External exam was preformed revealing complete vaginal atresia with fusion from the perineum with a 5mm opening just below the clitoral hood. We attempted to locate the urethral opening for foley placement however the opening was obstructed by the membrane. A small incision was made on the midline of the septum and a pediatric foley was placed successfully. A midline incision was made on the septum using a scalpel and carefully carried down to the level of the perineum. The vaginal mucosa was carefully dissected off the underlying tissue which appeared to be scared down. The vaginal mucosa was then reapproximated to the perineum using 3-0 vicryl in an interrupted fashion with special attention paid to bringing the vaginal mucosa to the entrance of the introitus. Redundant tissue was removed from the left labia and repaired in a running fashion. The introitus entrance measured 2 finger breaths following the procedure and hemostasis was achieved. Vaginal packing was coated in premarin cream and inserted. All instruments were removed from vagina. The patient tolerated the procedure well. All counts were correct times two. The patient was taken from the operating room in stable condition. The patient will go home after recovering from anesthesia and and meeting all the criteria for discharge. Pt was sent home with the remaining premarin cream to use nightly for the next 1 week. She will follow-up in 1 weeks in the office. Disposition: PACU - hemodynamically stable. I believed I could use CPT code 57130 but now I am thinking it may be closer to CPT code 56800? Please advise for confirmation of code. Thank you!

 

[nielynco]

Hello Group,

Please see procedure in detail below:

The patient was taken to Operating Room, identified 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. External exam was preformed revealing complete vaginal atresia with fusion from the perineum with a 5mm opening just below the clitoral hood. We attempted to locate the urethral opening for foley placement however the opening was obstructed by the membrane. A small incision was made on the midline of the septum and a pediatric foley was placed successfully. A midline incision was made on the septum using a scalpel and carefully carried down to the level of the perineum. The vaginal mucosa was carefully dissected off the underlying tissue which appeared to be scared down. The vaginal mucosa was then reapproximated to the perineum using 3-0 vicryl in an interrupted fashion with special attention paid to bringing the vaginal mucosa to the entrance of the introitus. Redundant tissue was removed from the left labia and repaired in a running fashion. The introitus entrance measured 2 finger breaths following the procedure and hemostasis was achieved. Vaginal packing was coated in premarin cream and inserted. All instruments were removed from vagina. The patient tolerated the procedure well. All counts were correct times two. The patient was taken from the operating room in stable condition. The patient will go home after recovering from anesthesia and and meeting all the criteria for discharge. Pt was sent home with the remaining premarin cream to use nightly for the next 1 week. She will follow-up in 1 weeks in the office. Disposition: PACU - hemodynamically stable. I believed I could use CPT code 57130 but now I am thinking it may be closer to CPT code 56800? Please advise for confirmation of code. Thank you!

In my opinion, this is more accurately coded as 56800. This was not a vaginal septum that divided the vaginal canal in half, rather, the vaginal opening was closed and needed to be opened.

 

[csperoni]

I agree with @nielynco. Particularly the "Redundant tissue was removed from the left labia and repaired" and "underlying tissue which appeared to be scarred down" would lead me to 56800.

 

[dmarshall]

I am so glad I reached out to confirm my coding choice and I appreciate your input as I am in total agreeance with you. Thank you so much!