Please help!!!
I'm looking for a CPT code for a patient who will be undergoing surgery to excise an area of her vagina.
The provider has stated in his dictation upon exam of the vagina: No lesions are seen. The vaginal cuff is intact and I did not see any granulation tissue or any exposed sutures. However, probing the upper left corner of the vaginal cuff with a Q-tip does reproduce her stated discomfort..
He then indicates in his plan:
The pain is easily reproducible with just superficial probing of the vaginal cuff on that left side. At this point with her being 2 years out (meaning, since her TVH, uterosacral suspension, and TOT sling), I have little hope that any further time will improve this. Therefore the one thing that I have offered her would be a local resection of this area.
Since he states no lesions are seen I can't use codes 11420-11426 which was my first inclination.
Suggestions anyone????????
I'm looking for a CPT code for a patient who will be undergoing surgery to excise an area of her vagina.
The provider has stated in his dictation upon exam of the vagina: No lesions are seen. The vaginal cuff is intact and I did not see any granulation tissue or any exposed sutures. However, probing the upper left corner of the vaginal cuff with a Q-tip does reproduce her stated discomfort..
He then indicates in his plan:
The pain is easily reproducible with just superficial probing of the vaginal cuff on that left side. At this point with her being 2 years out (meaning, since her TVH, uterosacral suspension, and TOT sling), I have little hope that any further time will improve this. Therefore the one thing that I have offered her would be a local resection of this area.
Since he states no lesions are seen I can't use codes 11420-11426 which was my first inclination.
Suggestions anyone????????