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Old 11-04-2010, 12:38 PM
melheffley melheffley is offline
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Default Vaginal Scare Tissue

I want to see if anyone can help me out with an op report. Patient was seen in the office with c/o pain with intercourse. Doctor diagnosed patient with vaginal constriction due to adhesions. Patient agreed to surgical treatment. Below is the op note.

Procedure: Excision of vaginal scar tissue, band tissue of the vagina.

Detail: ........bimanual exam showed a constriction of the vagine, band-type of scar tissue one-third of the way into the vagina. Rectal exam was done. Allis clamps were placed on the four quadrants of the band and a 1-2 cm area of the band was cut away in the four quadrants and the vaginal mucosa was reattached. This went from one finger being tight through this area to two fingers being placed and seperated slightly. The area was oversewn with a running 4-0 Vicryl. There was no involvement of the baldder or bowel to this area. It was all scar tissue on top of mucosa, and the upper vagina was normal with no scar tissue. The vagina was packed with Betadine-impregnated gauze which will be removed in recovery. She was taken to the recovery room in good condition.

What CPT would we be using for this? We have been searching but can't seem to find one that fits the situation/procedure. One co-worker thinks the correct code is 57200, but that seems to be repairing an injury (laceration) of the vagina. Can anyone help us out??

Thanks in advance!
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Old 11-04-2010, 04:19 PM
preserene preserene is offline
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to report 57200, ther should be an injury, recent injury, or any injury following a surgery.
there is no such description in your case.
I would very well consider 57260 , (which is closer to) combined anteroposterior colporrhaphy- the surgical procedures involved are meriting and closer to that(with band of tissues of the four quadrants comprising anterior an dposterior vaginal tissues and the revision or repair of them. No other suitable code is avaialble as far I know. Check with your Surgeon and if they amount to more wrok and time conception try to give Modifier 22

If (s) he feels it is overdoing, then go for appending to it -52.
nothing works out, go for13xxx or as a final and "our no other choice but 58999!
But I sincerely believe code 57260 could work out. an dofcourse with your documentation and diagnosis cod efor scar revision or /release or repair
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