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Posted By Maria on 11-06-2018, 14:17:03 in Ob-Gyn
Hello Melanie,

I am confused on this repair report given below.

Pt taken to OR for repairs.

I know the 4th degree is billable separately...but how about the Sulcus tear?

10 cm is saying that is how deep in her vagina the sulcus tear is?

I am think 1313X series but am unsure of the length of 4th degree.

Thanks for your help.

Maria


Preoperative Diagnosis:
1. Status post FT-SVD
2. Exam under anesthesia
3. 4th degree laceration with sulcus tear
4. Bilateral labial tear
 
Postoperative Diagnosis: same
 
Procedure: Exam under anesthesia with 4th degree laceration and sulcus tear repair and bilateral labial tear repair
 
Anesthesia: Epidural anesthesia
 
Estimated Blood Loss: 150 cc
 
IV Fluids: 700 of lactated Ringer's
 
Urine Output: not measured
 
Complications: none
 
Specimen: none
 
Findings: 4th degree laceration with sulcus tear and bilateral labial tear
 
Indication and Consent: This is a 26y.o. gravida 1 para 1 who is s/p a FT-SVD and found to have a 4th degree with sulcus laceration. The risks, benefits, and alternatives of the procedure were discussed with the patient. She understood the risks of the procedure. She wished to proceed and signed the consent.
 
Procedure Details: The patient was taken to the operating room where general anesthesia was administered without difficulty. She was placed in the dorsal lithotomy position with legs in the Allen-type stirrups. She was draped in the normal sterile fashion. An examination under anesthesia revealed a 4th degree laceration and 10 cm sulcus tear, with a bilateral labial tear.
 
The external anal sphincter was re-approximated with 2-0 vicryl in 4 different areas, posterior, superior, caudal and cephalad using figure of eights. The sulcus tear was found to be about 10 cm deep into the vagina, which was repaired with 3-0 vicyl in a running locked fashion, the 2nd degree aspect of the repair was closed in a routine fashion. The bilateral vaginal tears were repaired with 3-0 vicryl. Good hemostasis noted.
 
The patient tolerated the procedure well. The instrument and sponge counts were correct times two. The patient was awakened from Epidural anesthesia and taken to her L&D room in stable condition.
 



Comments (1)
Posted By Melanie Witt on 11-08-2018, 20:35:05
The 1313x codes required a complex repair which includes both layered closure of each wound but also tissue underpinning which I do not see described here. While you can use the simple repair codes for the genitalia (bilateral labial tears (the op note above says "vaginal" tears, but that is not correct) you do not have the measurement for that repair. For the sulcus tear, I think it could be 10 cm long (as the vaginal canal can be anywhere from 10-17 cm long), but there are no integumentary codes this is internal repair. In point of fact it is similar to the work for 57200 (with 8.59 RVUs but of course you cannot use that code since it stipulates non-obstetrical). I would therefore report this part of the repair using the unlisted code 59899 and compare it to 57200. For the other repairs - for the anus I would use an intermediate repair code of the mucous membrane and for the labial repairs the simple repair of the external genitalia code, but you will have to get measurements from the physician so that these can be reported. If you cannot, I would just go with the unlisted code 59899 and go with a repair that was similar to 57200 but a bit harder. No good answer for this one.
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