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Posted By Dorine on 04-12-2019, 11:32:10 in Ob-Gyn
Good Morning, Pt is status post robotically assisted vaginal hysterectomy in later Oct., she is now with 2 cm vaginal cuff dehiscence with portion of the colon sticking through the dehiscence with signs of colitis. Op report reads: Pt prepped speculum placed in vagina and rt angle retractor placed to visualize cuff, the vaginal dehiscence was found to have what appeared to be bowel protruding through it. Hysteroscope was brought into the operating room and assembled in working order. Vaginoscopy revealed presence of inflamed bowel protruding thru cuff, no sign of perforation noted or purulent discharge. Decision was made to irrigate the vaginal cuff and start IV antibiotics for possible colitis. Stitch of 3-0 Prolene was brought to the OR and vaginal cuff was reapproximated with a long suture tail. Following the reapproximation of the cuff vaginal was irrigated and cleaned, and hemostatic. Would it be appropriate to use the 58999 for the entire procedure. Your input is greatly appreciated. Thank you!
Comments (4)
Posted By Dorine on 04-19-2019, 09:50:48
No worries, thank you Melanie for your continued educational advice, you are appreciated!
Posted By Melanie Witt on 04-18-2019, 21:47:05
Oops, I meant 57420, not 57240.
Posted By Dorine on 04-15-2019, 15:53:27
Thank you, I looked in my OB/GYN Coding Companion in the CPT index and the Vaginoscopy code led me to 57452, glad I checked with you Melanie.
Posted By Melanie Witt on 04-15-2019, 14:08:41
Well, he did perform colposcopy of the vagina (57240) which I would bill for and then either add a modifier -22 (to account for the additional work doing the suturing), or you could add code 58999 for the suturing of the vaginal cuff (and compare that work to 12020).
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