# Post delivery cervical repair



## jdibble (Mar 11, 2013)

I need some help please.  The doctor delivered a baby vaginally.  The patient had retained placenta that was manually removed at bedside.  Following delivery the patient developed tachycardia and needed blood transfusion.  The doctor believed she had retained products from the delivery and decided to take the patient to the OR for a D&C. In surgery he saw a cervical laceration which he repaired and then performed the D&C but found no products of the placenta and concluded that the bleeding was from the lacerations.  (See the op note below.) 

Can this be billed separately from the delivery?  The doctor did not charge for this procedure stating that he believes it is part of the delivery.  I believe that this should have been billed as it was a return to the OR.  Codes I am thinking of are 57720-78 and 59160-78, but I am not sure if this is right.  

PREOPERATIVE DIAGNOSIS:   Suspected retained products versus cervical laceration with resultant anemia.

POSTOPERATIVE DIAGNOSIS:  Cervical laceration secondary to manual placenta removal.

PROCEDURE:  Postpartum dilatation and curettage with repair of cervical laceration.

ANESTHESIA:  General.

DESCRIPTION OF PROCEDURE:  The patient is a 39-year-old G2 P0-0-1-1 who delivered via vaginal delivery. Of particular note, she had a retained placenta that required manual removal at bedside.  It appeared to be removed in its entirety.  At the end of this particular delivery, approximately 600 mL of blood loss was noted and the mother was displaying some tachycardia in the 140s and some pallor.  The patient was under close observation after the delivery and the tachycardia did not resolve despite 2 L of lactated Ringer's.   She also complained of dizziness upon sitting upright.  A large clot of 300 mL was extravasated at that time with fundal pressure and a small area of membranes was noted in the clot. Hemabate was given at this time.  The uterus, however, was firm.  At this point 2 units of packed red blood cells were ordered; this was secondary to a CBC that was drawn during the event which revealed a hemoglobin in the 7.7 range, as this was an acute reading, we are suspecting the actual hemoglobin is much lower. As the Hemabate was given and packed red blood cells were ordered, more clots were noted and at this point it was decided to bring the patient back for an emergent dilatation and curettage with the suspicion for possible retained products secondary to the entrapped placenta.  Also of concern was possible cervical laceration secondary to the manual placenta removal. Due to body habitus, full evaluation of the cervix at bedside was limited.

The patient was taken back, prepped and draped in a normal sterile fashion. Betadine was used to sterilize the area.  She had already been receiving ampicillin secondary to low-grade fevers of 100.8 during labor. A weighted speculum was placed and good visualization of the area was noted. It was at this time when 2 bilateral posterior cervical lacerations were noted.  They were not currently bleeding at this time, however, it was clear that this needed to be repaired and 2-0 Vicryl on a SH needle was used to repair both bilateral cervical tears.  The cervix was patent and dilatation and curettage was undertaken and no retained products were acquired from the curettage.  It was determined at this point that the bleeding episode that she encountered was secondary to the cervical lacerations which were repaired at that time.

The patient tolerated the procedure well.  She was receiving her first and second units of packed red blood cells during the procedure along with lactated Ringer's in the opposite arm.  The patient was taken back to the PACU and she will be followed closely in the ICU overnight.  No uterine bleeding was noted during the procedure.  The patient will continue with ampicillin times 3 more doses.  She will be followed closely for any further bleeding issues.  A repeat CBC will be done 4 hours after the 3rd unit of packed red blood cells.


Please give me some opinions on what you think - if it is billable and the correct code seletions!

Thanks,


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## Thouvenel (Mar 11, 2013)

The 59160 is correct, and yes it can be billed for PP issues.


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## jdibble (Mar 12, 2013)

Thouvenel said:


> The 59160 is correct, and yes it can be billed for PP issues.



Thanks Thouvenel for your response. If I could just clarify this - so you would not bill for the cervical laceration repair?  And when you say it can be billed for post-partum issues - this would include the time period just following delivery?

Just want to make sure I understand this as I have to go back to the doctor and explain why he should have billed for this procedure!

Thanks again for your help!


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## Thouvenel (Mar 12, 2013)

You can't bill for the repair as it is part of the global delivery.  But you can the PP curettage of 59160, and I would recommend using the 666.14 and 665.34


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## jdibble (Mar 14, 2013)

Thank you very much!  That was very helpful.


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