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perineal "dog ears"

  1. #1
    Default perineal "dog ears"
    Clearnace Sale
    Need help in finding a code for redundant skin "dog ears" in the perineal after a vaginal delivery. Patient was taken into surgery 8weeks after delivery to remove the dog ears caused from the sutures. Our doctor states this is a perinealplasty but the documentation does not support that procedure since this is removal of extra skin from sutures.

  2. #2
    Milwaukee WI
    Default 52 modifier?
    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

  3. #3
    Thank you for your help!!!!

  4. #4
    does the report sound more like an excision of excess skin than an actual perinealplast??
    if so the code i have used is 15839 which alot of insurances wont pay without explination and documetation.
    if this sounds more like a scar revision (doubtful since so early after delivery) but the code range i have used for scar revision is the complex repair codes(scar revision is in the description).
    hope this helps
    Christine G. CPC

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