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need help!!!

  1. Unhappy need help!!!
    Medical Coding Books
    Hi Ob/gyn coders:

    patient asked that vaginal polyp be removed. We agreed to consider this. On vaginal exam, the patient had a significant tear of the vagina, which resulted in a large exophytic area of tissue. If I had excised the tissue only, she still would have had a mass bulging out of the vagina; it required me to excise the torn area and then make an incision-all on the left side-on the right side to reapproximate the tissue in a standard manner. This, however, took longer than expected-approx 20 minutes to complete.

    I used 3-0 Vicryl to close the vaginal mucosa and the rebuild the perineal body. The perineal body was closed in a standard manner and subuticular was used to close the skin. Bipolar cautery to acquire hemostasis and 1% lidocaine was injected.

    Complications: Large tear in vaginal wall had healed in the large exophytic tissue.

    Path Sent: Came path Vaginal Polyp

    I'm confused w/ this one....any thoughts???

  2. Default need help!!!
    Hi Jamie,

    I think you could use the 57135 - Excision of vaginal cyst or tumor with a modifier 22 for the additional work assuming that an extra 20 minutes is 25-50% more time than the procedure would normally take you to complete. I would suggest 623.7 - polyp of vagina and 623.4 - old laceration of vagina as the diagnosis codes based on your post.

    Ruth Perkins, CPC, COBGC

  3. Default
    Thanks Ruth for your help!!!

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