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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


 








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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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