AHA Coding Clinic® for HCPCS - 2025 Quarter 4; Ask the Editor
Colpocleisis with Colporrhaphy and Perineorrhaphy
A patient presented for Le Fort colpocleisis with posterior colporrhaphy and perineorrhaphy to treat complete uterovaginal prolapse. The cervix was grasped with clamps, and the prolapse was exteriorized. Rectangular areas were marked and sharply dissected on the anterior and posterior vaginal walls, maintaining a 3–4 cm distance from the urethral meatus. The vaginal epithelium was sharply dissected off the underlying fibromuscular layer starting with the anterior vaginal wall followed by the posterior vaginal wall. A perineal incision was also made during posterior wall dissection. Two lateral Allis clamps were applied at the posterior introitus and approximated to ensure adequate tension-free perineorrhaphy. A horizontal incision was made, and excess vaginal and perineal epithelium was excised. Rectangular raw surfaces on the anterior and posterior vaginal walls were then approximated. The epithelium near the cervix was first sutured together using 2-0 Vicryl, effectively imbricating the cervix. Continuous 2-0 Vicryl sutures created channels, and the fibromuscular layers were imbricated with serial interrupted 0-Vicryl sutures. Three rows of sutures achieved complete prolapse reduction, including correction of the enterocele. Attention was then directed to posterior repair and perineorrhaphy. Interrupted 0-Vicryl sutures reapproximated the posterior vaginal fascia and perineal body muscles to narrow the genital hiatus. Closure of the anterior and posterior vaginal walls was incorporated into the repair, completed with 2-0 Vicryl. Hemostasis was confirmed throughout. When a posterior colporrhaphy with perineorrhaphy is performed in addition to Le Fort colpocleisis should it be additionally reported? ...
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Article Overview
This premium article explains an operative case involving pelvic organ prolapse surgery and the combined repair steps used during the procedure. It is relevant to gynecology, urogynecology, and surgical coding professionals who need to understand the overall scope of the operation and the clinical documentation context without relying on the full article.
Why This Topic Matters
Pelvic reconstructive procedures are often documented together, and accurate interpretation of the operative note helps determine the appropriate coding and reporting context. The article is useful for professionals reviewing surgical terminology, procedure grouping, and documentation patterns for prolapse-related repair.
What You Will Learn
- How the operative note frames the prolapse repair procedure
- How combined vaginal and perineal repair components are described in surgical documentation
- What broad clinical context is associated with this type of urogynecologic case
- How the documentation supports understanding of the overall operative scope
Who Should Read This
- Medical coders
- Coding auditors
- Urogynecology staff
- Gynecology providers
- Clinical documentation specialists
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