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Posted By Danielle Levy on 01-09-2018, 16:43:45 in Ob-Gyn
Our physician performed an excision of posterior vaginal scar excision. Pathology comes BACK AS : benign FRAGMENTS OF VAGINAL SQUAMOUS SHOWING SCAR FORMATION WITH FIBROSIS AND CHRONIC INFLAMMATION . Would I use 13131? Please advise . thanks
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Posted By Melanie Witt on 01-12-2018, 14:43:31
I doubt this was a complex repair as defined under CPT “includes the repair of wounds requiring more than layered losure, viz., scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations
or avulsions.” You will have to dig into the operative note to find out the details of the repair after the scar was removed and also look at the size of scar, but still the vaginal canal is not external genitalia which would be required to use a code listed in the integumentary system. In effect, because it was benign and on the vaginal wall the work was probably more akin to 57135 or 11420-11426, but you can't use these codes because, 1) it was not a cyst or tumor of the vagina, and 2) the scar was not on the external genitalia which is the intent of the 1142x codes. You best option in my opinion is the unlisted code 58999 and compare the work to either 57135 ( 5.46 RVUs) or 11422 (5.04 RVUs) if the lesion was between 1.1 and 2.0 cm.
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