Coding, Classification & Reimbursement

Vaginal laceration

  • 1.  Vaginal laceration

    Posted 6 days ago
    ​​Can anyone tell me what CPT code to use for cauterization of a vaginal laceration due to intercourse? This repair was done in the ER. A simple repair does not seem to work because it states external genitalia. I'm looking at 57200 but it states suture of vaginal injury and this wound was not sutured.

    Any ideas?


    >>2 cm R vaginal wall laceration hemostasis obtained using silver nitrate stick. Patient continued to have slight ooze post procedure<<


    Thank you,

    Annie

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    Anne Fieberg-Thornton
    Coder
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  • 2.  RE: Vaginal laceration

    Posted 4 days ago
    Edited by Jill Myers 4 days ago
    ​I'd look at 17106-17110. That's a tough one!

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    Tennille Dick
    Coder
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  • 3.  RE: Vaginal laceration

    Posted 3 days ago

    Hi, Annie:

    This is an interesting case. A quick check of CPT/HCPCS Coding Clinic and other sites didn't reveal anything.

    You're right -- 57200 is for suture of vaginal injury and this wound was not sutured, so I would not use that.

    I did find where 12041 is a repair of a complex wound includes genitalia with no distinction between internal or external, but it doesn't sound like this was a complex wound. CPT chapter notes call chemical "cautery" a simple repair. I don't know if appending a 52 Modifier for reduced services would work here.

    The 17106-110 codes are for DESTRUCTION of LESIONS.There are no lesions in this case. Further, there is a specific note saying we CANNOT use related 17250 to report chem cauterization for hemostasis.

    This might be an actual case of an Unlisted procedure, Female Genital System, 58999, and send along detailed notes.

    Let us know what code you finally use!



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    Thank you!
    Cynthia Kibbe
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  • 4.  RE: Vaginal laceration

    Posted 2 days ago
    Hi everyone.  I would use the cpt code 57180, "Introduction of any hemostastic agent or pack for spontaneous or traumatic nonobstetrical vaginal hemorrhage. Separate procedure."  There is a Cpt Assistant November 07, page 1.  Unfortunately, I do not have access to it at this time.

    This was an interesting case to research!

    Thanks.

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    Cheryl Anderson, CCS, CCS-P
    Coding Auditor
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  • 5.  RE: Vaginal laceration

    Posted 2 days ago
    Cheryl, you're a genius! I didn't even see 57180. I quickly indexed through the CPT book, but it led nowhere. I'd use this code, too.

    I believe I found the CPT Assistant Nov 2007 note:

    "Pelvic examination under anesthesia (57410), laparoscopy with or without collection of specimens (49320), myomectomy with excision of one to four myomas (58140), laparoscopic removal of adnexal structures (58661), laparoscopic fulguration of oviducts (58670), and laparoscopic occlusion of oviducts by a device such as a band or clip (58671) are all inclusive components of codes 58541-58544 and should not be reported in addition to these codes (ie, do not report 58541-58542 in conjunction with 49320, 57000, 57180, 57410, 58140-58146, 58545, 58546, 58561, 58661, 58670, and 58671)."

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    Thank you!
    Cynthia Kibbe
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