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Posted By Danielle Levy on 12-17-2019, 12:35:50 in Ob-Gyn
Melanie,
Our physician stated he did a perineal fistula repair, however after reading the operative report it states fistula tract going from hymen distally and coming out just above the anal verge with no involvement of the external anal sphincter. How would we code this ? Would it result in an unlisted code? I have attached the op report for your review . Thanks
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  1. OP REPORT .pdf
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Posted By Melanie Witt on 12-19-2019, 13:01:36
In my opinion the was a perineoplasty procedure. The hymen (when present) is located at the opening of the vagina and he did incise the tissue from there to just in front of the anus and this fits the description of code 56810. As you say, there was no anal involvement so the procedure does not rise to the level of a rectovaginal fistula repair. Remember to code this diagnostically as a late effect of pregnancy.
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