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Posted By anita lawnick on 04-06-2018, 11:19:23 in Ob-Gyn
20 cc of lidocaine injected into the laceration site. A rectal exam was performed and there was noted to be an approximately 1cm tear into the rectal mucosa. The rectal mucosa was repaired with a running suture of 3-0 vicryl and a second imbricationg layer was placed. Only 2-3 stiches required. A rectal examconfirmed no sutures in the rectum. Allis clamps were used to grasp the internal anal sphinctar bilaterally and 3 inturrupted sutures were plaved through the IAS.The external anal sphincter was reapproximated with mattress sutures. The second degree laceration was then repaired in the usual fashion with 2-0 vicryl rapide reapproximating the vaginal mucosa deeper subcutaneous tissue in a running locked fashion. The perineal skin was reapproximated 3-0 vicrylrapide in subcuticular fashion. Rectal exam confirmed good tone and repair.

Would cpt 13131 be appropriate or should I just use 59400 mod 22?

Thanks in advance for the help.
Comments (2)
Posted By anita lawnick on 04-06-2018, 16:28:16
Thank you Melanie...truely appreiciate you input
Posted By Melanie Witt on 04-06-2018, 15:50:26
I would not classify this as a complex repair as there was no debridement or extensive undermining of the laceration. At best this was an intermediate repair of the anus and rectal mucosa, neither of which has its own specific CPT code. I would also not consider these to be "external genitalia" so the intermediate repair codes would also not be correct. You can use the unlisted code 45999 or 46999 and compare the work to an 1205X CPT code (but you will need to know the repair measurements) or as you have suggested apply a modifier -22 to the global OB code and make a case for additional payment.
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