A woman with a long history of rectocele and perineal scarring from multiple episiotomies develops a rectovaginal fistula with perineal body relaxation. She has transperineal repair with perineal body reconstruction and plication of the levator muscles. What are the CPT® and ICD-10-CM codes reported for this procedure?

Question

Patience Tran

Biology

25 June, 04:49

A woman with a long history of rectocele and perineal scarring from multiple episiotomies develops a rectovaginal fistula with perineal body relaxation. She has transperineal repair with perineal body reconstruction and plication of the levator muscles. What are the CPT® and ICD-10-CM codes reported for this procedure?

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Jovani Crane · Answer 1

N82.3

N90.89

Explanation:

In this case, the patient has a history (not current) of the rectocele

The first diagnosis is rectovaginal fistula (Alphabetic Index for Fistula/rectovaginal is N82.3).

The second diagnosis isperineal scarring (Alphabetic Index for Scar, scarring/vulva is N90.89)

Therefore, code N81.6 won't be reported since it's stands for a current rectocele