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Posted By Mary Peabody on 06-18-2020, 16:12:16 in Ob-Gyn
Hello Melanie,

I am trying to find a CPT code for this procedure and I am really not sure. Would you report this with CPT 13160?

PREOPERATIVE DIAGNOSIS: Necrosis of rectus abdominis myocutaneous
flap neovagina
POSTOPERATIVE DIAGNOSIS: Necrosis of rectus abdominis myocutaneous
flap neovagina, final pathology pending
OPERATION: Examination under anesthesia with debridement of
myocutaneous flap as well as proctoscopy

OPERATIVE PROCEDURE: The patient was taken to the operating room
with an IV in place. Sequential compression devices were placed on
the lower extremities. She was placed in dorsal lithotomy position.
Examination under anesthesia was performed. She was noted to have
circumferential and total necrosis of her myocutaneous flap
neovagina. We excised the devitalized tissue and cultured the tissue
for both bacterial cultures as well as fungal cultures by tissue. We
debrided all of the nonviable tissue, which included the pedicle
reaching up to the patient's left. We were able to excise the
devitalized tissue that included the underlying fat and muscle. We
were able to gently debride the last layer of devitalized tissue
using a small gynecologic curette. There was some bleeding noted in
the bed that was made hemostatic with both Bovie electrocautery as
well as pressure. In the end, the flap was excised without apparent
extension into the peritoneal cavity. She was noted to have good
hemostasis and a plan was made for daily irrigation. We performed a
rigid proctoscopy to examine the rectum, which was noted to be
intact. At this point, the procedure was felt complete, and we took
the patient out of lithotomy, awakening her from anesthesia, and
transferring her to recovery room in stable condition.
Comments (1)
Posted By Melanie Witt on 06-19-2020, 15:43:54
Your closest code is 11004 except that this was not external genitalia. 13160 means it was performed on skin, not the vaginal canal so I would not use that code. Instead go with unlisted 58999 and compare the work to 11004.
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