Find out what colporrhaphy code you’ll use for an injury repair.

If you’re stuck trying to figure out what code to use for a vaginal cuff repair, you should ask yourself one main question: Why did the ob-gyn need to perform the repair?  The answer is the best way to decide what code (and possibly modifiers) to choose.  Follow these three expert steps, and you’ll find the solution to one of the most frequently asked questions in an ob-gyn office: “Which CPT® code should I use for repair of vaginal cuff?”

Q1: How Do I Decide What Repair Code to Use?

The first thing you should do when the ob-gyn performs a vaginal cuff repair is examine the operative report to determine why the patient required the repair, says Cindy Foley, Billing Manager for three separate gynecology practices in Syracuse, N.Y.

Q2: If Repair Dealt With Loose Sutures, What Should I Do?

You read your op notes and discovered the vaginal cuff repair dealt with loose sutures.  Suppose the patient, who underwent a total abdominal hysterectomy (58150, Total abdominal hysterectomy corpus and cervix], with or without removal of tube[s],with or  without removal of ovary[s]), needs to return to the operating room for a vaginal cuff repair because the original sutures became loose and a simple re-closure is documented.  In this case, you should report 58999 (Unlisted procedure, female genital system [nonobstetrical]). You would also need to submit your op report along with a cover letter that explains in simple, straightforward language exactly what your ob-gyn did, says Melanie Witt, RN, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M.

Remember to explicitly reference the nearest equivalent listed procedure in your explanatory note. For example, you might consider comparing the work to 12020 (Treatment of superficial wound dehiscence; simple closure), which...