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Posted By Danielle Levy on 01-24-2018, 18:21:27 in Ob-Gyn
Our physician performed EUA of the entire vaginal vault, endocervical canal, anterior & posterior vaginal walls for a retained stitch .

The report states : The entire area over a period of 5 to 10 minutes was completely scanned . On palpation, there was fibrotic and knotty region in the right posterior lateral fourchette. This I though may have been a prolene knot or retained cerclage. It was not . However the area was opened, explored and excised . Approximately 1CM piece of tissue was removed but not sent to pathology . This area once tissue was removed was electrocauterized and hemostasis was noted. The entrance wounds to the cervical cerclage needle were fully examined, the endocervical was examined . Thus there was a vaginal removal of fibrosis on the right fourchette.

How would this be code ? Any suggestions would be greatly appreciated .
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Posted By Melanie Witt on 02-02-2018, 17:31:05
First, the last time I looked the fourchette was outside of the vaginal vault and applies to the site of an episiotomy, not a cerclage suture which would have involved the cervix. Even though he say vaginal removal of the right fourchette, that implies to me that he removed a piece of tissue via the skin, not the vaginal wall. In that case if it was 1 cm I would go with the integumentary code 11421 and EUA would of course be bundled. There is no code for removal of the tissue from the vaginal wall so that would have to be an unlisted procedure, 58999.
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