# help!-My doctor is a



## mamacase1 (Mar 14, 2011)

My doctor is a family practice doctor that had a patient come in post 2 days delivery. Dictation says pt is here for check status post delivery.  She did have a vaginal delivery 2 days ago and felt like stitches tore here recently.  Exam : There is no active bleeding.  On the posterior fornix there is a samll are that is open a little bit but tissues are staying cloased and I do not see this is an open wound.

DX:  Recheck status post delivery with torn episiotomy

At this point in time no fruther treatment will recheck in about a week to see houw this is doing.

I would of thought that she would have followed up with her OB/GYN but since she didnt how would you colde this. ICD9?


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## btadlock1 (Mar 14, 2011)

mamacase1 said:


> my doctor is a family practice doctor that had a patient come in post 2 days delivery. Dictation says pt is here for check status post delivery.  She did have a vaginal delivery 2 days ago and felt like stitches tore here recently.  Exam : There is no active bleeding.  On the posterior fornix there is a samll are that is open a little bit but tissues are staying cloased and i do not see this is an open wound.
> 
> Dx:  Recheck status post delivery with torn episiotomy
> 
> ...



cpt 59430, 665.5, V24.2 (I think)


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## mamacase1 (Mar 16, 2011)

Thank you for your help Brandi


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## lisahair (Mar 16, 2011)

I would not use the CPT 59430. This would be a low level E/M. For the ICD-9, I would go with the 665.54. I don't care for the V24.2, this was not really a routine postpartum follow up.

Lisa Hair, CPC, CPMA


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## Grintwig (Mar 16, 2011)

What about 674.24 (other specified complications of the  puerperium, NEC; disruption of perineal wound; disruption of wound episiotomy; postpartum condition or complication) as a diagnosis code?


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## btadlock1 (Mar 16, 2011)

Grintwig said:


> What about 674.24 (other specified complications of the  puerperium, NEC; disruption of perineal wound; disruption of wound episiotomy; postpartum condition or complication) as a diagnosis code?



I like that one better than either of mine...


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## Grintwig (Mar 23, 2011)

My intern found it


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## MJ4ever (Apr 1, 2011)

I agree with 674.24 with an E&M w/ modifier 24 (because it is in the global delivery time frame)
Postpartum 59430 is coded for the standard postpartum at the estimated 6 wks after delivery.


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