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any suggestions

  1. #1
    Default any suggestions
    Medical Coding Books
    need some suggestions on what people think to code on this? this was coded 57308.

    Rectovaginal fistula.


    Rectovaginal fistula.

    PROCEDURE: Rectovaginal fistula, posterior repair.

    ANESTHESIA: General.

    INDICATIONS: The patient is a 54-year-old white female who has had a known rectovaginal fistula for years of approximately 1 mm. The patient has recently decided she would like it repaired. The risks, benefits, and alternatives including bleeding, infection, injury to bowel or bladder as well as operative plan were discussed with the patient. The patient consents to the procedure.

    DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and prepped and draped in the dorsal lithotomy position. Of note, she did have a bowel prep the day prior to surgery. She was placed in the dorsal lithotomy position. The fistula was identified with a lacrimal duct probe. The perineal skin was anesthetized with Marcaine and then incised with a scalpel. The vaginal mucosa was dissected laterally around the fistulous tract. The fistulous tract was then grabbed with an Allis clamp and removed with Metzenbaum scissors. The tract was then closed with 3-0 Vicryl and then imbricated over with a second 3-0 Vicryl. The puborectalis fascia was then imbricated over the fistulous tract, and then the vaginal mucosa was closed. The patient tolerated the procedure well and was sent to recovery room in stable condition.

  2. #2
    Milwaukee WI
    Default Check CPT Index
    Check your CPT index under
    Repair - Fistula - Rectovaginal

    Thank should give you the appropriate start to find the code that matches your documentation.

    F Tessa Bartels, CPC, CEMC

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