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Question: I need help determining which would be the appropriate code for this. The procedure notes state:

Patient had a vaginal delivery 2 months ago during which she sustained a right labial laceration that was repaired at that time.

During her postpartum visit a month later, she reported irritation of this laceration and was advised to come in for a revision at the office, because it did not heal completely after delivery.
She then came back a few weeks later for this.

This was the physician鈥檚 documentation: 鈥淟idocaine with epinephrine 1% was injected into the area of separation. Edges were then excised and freshened. The two edges of the separation were then reapproximated using 2-0 vicryl rapide. Patient was advised to follow up in one week.鈥�

I think the appropriate code would be 12041, but the physician used 59300. Who is correct?

Texas Subscriber

Answer: You are correct. You should not report 59300 (Episiotomy or vaginal repair, by other than attending) in this instance, because an episiotomy had already been performed and is not being repaired. The correct code would be 12020 (Treatment of superficial wound dehiscence; simple closure) as this was a simple closure (not intermediate) of the separation.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor