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Posted By Maria on 04-27-2021, 06:31:18 in Ob-Gyn
Hello Melanie,

I have a dr that did a 58252 vaginal hysterectomy.

He also performed a Perineoplasty for a gaping vagina.

His findings were "Perineum widening and redundant tissue."

The note " The widened perineum was clamped at 4 points with Alis clamps. The perineal skin was incised with the scalpel and removed. The defect was reapproximated with 0-vicryl figure of 8 stitches. The mucosa was reapproximated with 2-0 vicryl. Two fingers were able to be placed in the introitus without difficulty."

Would the correct codes be 56810 or 57210?

Dx codes n90.89 or n81.89?

Thanks, Maria


Comments (1)
Posted By Melanie Witt on 05-03-2021, 14:55:06
I would go with 56810 since an injury to the vagina or perineum is not documented.. Although this is a CPT "separate procedure", code 56810 is not bundled into 58252. I would also report N90.89.
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