Question

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?

Answer 1

N82.3

N90.89

Step-by-step 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