Case Studies in Coding: Coding for colpopexy

Each year CPT introduces new codes and makes revisions to existing codes to better reflect current medical practices. CPT 2005 is no different. This month, we’ll look at changes in coding for vaginal colpopexy. The 2005 CPT codes reflect the expansion and improvement of surgical techniques in the area of female reconstructive surgery.

A visit to Dr. Thatcher Ms. Douglas is a 74-year-old patient who comes to Dr. Thatcher's office with complaints of increasing vaginal pressure and discomfort. She complained of the symptoms at the time of her last well-woman examination and was offered, but refused, surgery. She is now complaining of worsening vaginal bulging, particularly after lifting and prolonged standing. She denies urinary incontinence but admits to some bladder pressure and urinary frequency. She delivered all four of her children vaginally. Her past medical history is otherwise negative. On physical examination, Dr. Thatcher notes significant inversion of the vaginal apex extending into the external genitalia. She also notes an enterocele at the vault of the apex.

Dr. Thatcher again discusses surgical options with Ms. Douglas, including laparoscopic, abdominal, and vaginal approaches. She prefers the vaginal approach and wants to schedule surgery as soon as possible.

On the day of surgery, Dr. Thatcher reviews Ms. Douglas' records and meets with her briefly to answer any remaining questions.

Ms. Douglas' surgery

Dr. Thatcher examines the vaginal defect and then opens the vaginal mucosa at the vaginal apex. Next, the anterior and posterior endopelvic fascia is dissected away from the mucosa, exposing the enterocele. The peritoneum is identified and entered sharply under direct visualization. The bowel is retracted away and packed. The ureters and uterosacral ligaments are identified bilaterally. The uterosacral ligaments high in the pelvis are grasped with clamps and placed on traction. Next, a series of interrupted sutures are placed through the uterosacral ligaments on both sides. A culdoplasty is performed to obliterate the

cul-de-sac. Dr. Thatcher brings the sutures through the exposed anterior (pubocervical) and posterior (rectovaginal) endopelvic fascia. Then the sutures are tied to suspend the vagina deep in the pelvis. The vaginal vault is closed with interrupted sutures. A Foley catheter is placed and left in for bladder drainage. Finally, the vagina is packed with gauze and Ms. Douglas is taken to the recovery room in stable condition.

Surgical follow-up Dr. Thatcher speaks with Ms. Douglas' family, completes postoperative orders, and dictates the operative report. She sees Ms. Douglas in the hospital later that day and each day that the patient remains in the hospital. On the day of discharge, Dr. Thatcher sees Ms. Douglas, discharges her from the hospital with instructions, and completes the necessary paperwork, including the discharge summary. Before releasing Ms. Douglas from care, Dr. Thatcher sees her in the office for routine surgical follow-up.

How would you have coded this case? Read on for the report of services and an explanation of the code.