Question Vaginal Cyst excision with posterior repair

[krista2178@yahoo.com]

MD describes this procedure as a vaginal cyst excision with posterior repair. This looks like more than just a 57135 and assuming the repair would be included in the procedure. How would you code this?? The hymenal ring was identified and grasped with two Allis clamps at the 7 and 5 o'clock positions. This area and the mucosa surrounding the vaginal cyst was then injected with 0.25% marcaine with epinephrine. A triangular shaped incision was made at the posterior fourchette using the scalpel and the vaginal epithelium was dissected off sharply. This dissection was extended approximately 6cm proximal with Metzenbaum scissors circumventing the vaginal cyst. The vaginal mucosa was then grasped with Allis clamps and the vaginal cyst was meticulously dissected off of the underlying rectum sharply. The rectovaginal septum was extremely attenuated and towards the apex of the vaginal cyst the cyst wall was quite close to the rectum. Due to this, the majority of the cyst wall dissection had to be performed with a surgeon's gloved finger in the rectum to avoid rectal injury. In the process of dissecting out the full length of the cyst, several varicosities were encountered which contributed to larger blood loss. These sinuses had to be sutured with interrupted sutures of 0-Vicryl along the way in order to maintain hemostasis and visualization. In the process of completely excising the cyst, the posterior cul-de-sac was entered without injury to bowel. The cul-de-sac was completely closed with 2-0 Vicryl after the cyst wall was excised. Once this was closed, hemostasis was obtained with a combination of electrocautery, sutures and eventually thrombin-soaked foam once the majority of the oozing was controlled. The rectovaginal septum was then rebuilt with multiple imbricating layers of 2-0 and 0 Vicryl. The rectovaginal septum was then re-attached to the perineal body using 0-Vicryl. During and after the procedure, care was taken not to narrow her introitus. The vaginal mucosa was then trimmed and closed similar to the manner of an episiotomy with running 2-0 vicryl.

 

[csperoni]

Not my exact area of expertise, as this type of procedure is usually done by pelvic reconstructive specialists around here.
This looks to me like possibly 57250 for posterior colporrhaphy with rectocele repair. While the provider does not use that terminology, it seems to be very similar to what is described.
I would also want to clarify that needing this repair was not caused by the surgery, but rather the pre-existing condition. If it is an injury the surgeon created, you cannot bill to repair it.

I would query the provider on this. If it was not created by surgeon, and 57250 is not appropriate, then I recommend 57135 with modifier -22.

Hope that helps!