The lay description for 56810 is:
With upward traction on the vagina, the physician makes an incision from the lower vaginal opening to a point just in front of the anus. The underlying weakened tissues are dissected and repaired and tightened by suturing. This restores strength to the pelvic floor, closes tissue defects, and improves function of the perineal muscles.
You say his documentation doesn't support this. Not seeing the entire documentation it's impossible for me to tell for sure, but would it be appropriate to code 56810 with a 52 modifier (reduced service)?
F Tessa Bartels, CPC, CPC-E/M
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