A 59-year-old patient with uterine prolapse with cystocele presents for anterior repair. At surgery, a linear incision was made from the vaginal cuff to below the urethra and the vaginal mucosa was dissected off the pubovesical fascia with sharp and blunt dissection. The pubovesical fascia was then re-supported in the midline with layered sutures, thus reducing the cystocele. Is “repair” the appropriate root operation for the anterior cystocele repair? If so, there does not appear to be an appropriate approach value for the anterior repair of the cystocele. What is the appropriate code assignment for this procedure?
Yes, “Repair” is the correct root operation for procedures performed to treat cystocele, rectocele and enterocele. Assign the following ICD-10-PCS code:
0JQC0ZZ Repair pelvic region subcutaneous tissue and fascia, open approach
In this case, an open approach is coded, because "a linear incision was made from the vaginal cuff to below the urethra" to expose the pubovesical fascia directly, and then the repair was performed.