# Help me learn OB GYN coding PLEASE !!



## KCOPPENRATH (Aug 26, 2010)

Good morning, 
    I am attempting to learn Ob gyn coding on my own and I am having some difficultys getting it. I have signed up to code some operative reports but I have gotten two out of 5 done. I have been searching for a diag for this report and for some reason I am not getting this. Please someone help me to understand this and if you have any advise that would be helpful please feel me in : 

Procedure code : 58611 


PREOPERATIVE DIAGNOSES:
1. A 39 weeks' gestation intrauterine pregnancy.
2. Previous cesarean section, desires repeat.
3. Platelet function disorder.
4. Undesired fertility.

POSTOPERATIVE DIAGNOSES:
1. A 39 weeks' gestation intrauterine pregnancy.
2. Previous cesarean section, desires repeat.
3. Platelet function disorder.
4. Undesired fertility.

ANESTHESIA: General endotracheal.

NAME OF OPERATION: Repeat low transverse cesarean section with bilateral tubal
ligation, modified Pomeroy technique.

ESTIMATED BLOOD LOSS: 500 milliliters.

FLUIDS: 3200 milliliters crystalloid.

COMPLICATIONS: None known.

FINDINGS: Viable female infant, Apgars 9 at one minute, 10 at five minutes, weight 3110 grams. Spontaneous delivery, intact placenta, three-vessel cord.

DISPOSITION: Infant to newborn nursery, mom to recovery room.

PROCEDURE DETAILS:
Patient is a 34-year-old G2, PI at 39 weeks' gestational age who presents for repeat cesarean section. Patient a known underlying platelet function disorder. She has received desmopressin preoperatively with other procedures and done well with this. Blood blank has available two six-packs of platelets, and she has been typed and crossed for 4 units of blood.

The patient understands the increased risk for bleeding in her case. Otherwise, the remainder of the risks of the procedure have been discussed with her and proper consent is obtained.

The patient was taken to the operating room where she underwent Foley catheterization and SCDs to the lower extremities. She was placed in the dorsal supine position with leftward tilt and prepped and draped in the usual sterile fashion. With personnel attending scrubbed and ready to proceed, she underwent general endotracheal anesthesia.

A Pfannenstiel incision was then recreated, carried down to the level of the rectus fascia, which was incised in the midline and lateralized on either side. The superior aspect of the fascia was tented upward, dissected sharply and bluntly away from underlying muscles. In similar fashion, this was performed on the inferior aspect of the fascia. The rectus muscles were separated in the midline. Peritoneum was entered and rectus muscles lateralized bluntly. Bladder blade was placed. Uterovesical reflection was visualized and bladder flap created sharply and bluntly and bladder blade replaced to protect the bladder.

Low transverse hysterotomy was then performed. Uterine cavity was entered with blunt end of the scalpel. Hysterotomy was lateralized bluntly. Artificial rupture of membranes was performed. Clear fluid was noted to be present.

The infant's head was delivered out of the pelvis. Fundal pressure was applied. The infant's head was delivered followed by anterior shoulder, posterior shoulder and remainder of body without difficulty. Infant's oropharynx and nares were bulb suctioned. Cord was clamped times two and cut. The infant was handed off the attending physician, Dr. _____.

Cord ABG, venous blood gas and cord blood sampling was obtained. The placenta was delivered spontaneously intact. Uterus was exteriorized and wrapped in a wet lap. Uterine cavity was cleared of all clot and debris.

Hysterotomy was reapproximated using 0 Polysorb in continuous running locked fashion followed by a reimbricating layer of 0 Polysorb. Any areas of oozing were meticulously cauterized. Area of oozing along the right midline to right lateral edge of the incision was replicated with three figure-of-eight sutures. Hemostasis was evident thereafter.

Attention was then turned to performing tubal ligation. The right fallopian tube was isolated, and the ampullary portion of the tube was tented upward with a Babcock clamp. Two serial sutures of 3-0 plain were placed in order to isolate a knuckle of approximately 1 centimeter of tube. This portion of the tube was then excised. Ends were inspected and found to be hemostatic. Specimen sent to pathology.

In similar fashion, the left tube was isolated, suture ligated and portion of tube excised. Once, inspected ends of the tube and found to be hemostatic.

Attention was once again turned to the hysterotomy incision and found to be hemostatic. The posterior aspect of the uterus was inspected. No defects or hematoma was forming. The region was well irrigated, suction dried. Uterus was returned to the abdomen. Colonic gutters were cleared of all clot and debris, well irrigated and suction dried.

Right fallopian tube operative site was inspected, and a small amount of oozing was noted along the medial aspect of the tube. Therefore, this was simply plicated with a 3-0 Polysorb on a GI needle. Hemostasis was then evident. The left fallopian tube operative site was inspected and found to be hemostatic. Hysterotomy was once again inspected and found to be hemostatic.

Rectus muscles were then reapproximated using 0 Polysorb in inverted mattress suture technique. Anterior aspect of the muscle followed by posterior aspect of the fascia were inspected and found to be hemostatic. Rectus fascia was reapproximated using 0 Polysorb beginning laterally on either side and meeting in the midline. Subcutaneous tissue was well irrigated and suction dried. Any areas of oozing were once again meticulously cauterized. Hemostasis was evident. Skin was reapproximated using staples. Uterus remains firm.

The patient tolerated the procedure well. Instrument, sponge, needle counts were correct times two.

We will be monitoring the patient very closely for any evidence of bleeding. She did receive her desmopressin preoperatively and responded well to this. She did receive 2 grams of Ancef after cord clamp for prophylactic antibiotic


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## tcruz (Aug 27, 2010)

Try looking at 59510 for c-section if whole global package is being billed out or 59514 if only c-section is being performed, minus the antepartum care. Your second procedure would be an add on code of 58611 for the tubal done during c-sect. Dont forget to use ICD-9 of 654.21 if this is a repeat c-sect. Hope this helps!! It can be pretty tricky, I know because I am new at it too!

Good Luck!

T. Cruz


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## preserene (Aug 27, 2010)

Perfect. 
But I would like to add some more diagnosis codes along with previous LSCS code because they are as much and even much more of medical necessity for this repeat cesarean antenatal/intrapartumor postpartum complication health hazard.
Patients history of platelet disorder and being on prophylactic measures are very important, related to the present cesarean. Platelet disorder and the prophylactic management give a great concern of her pregnancy and postdelivery/post-cessarean health hazard; any time time she can go for coagulation disorders/or HELLP Syndrome like condition, which is life threatening.
So* Vcodes V12.3* for personal history of Diseases of blood and blood F. organs, and *V07.8 *for other specific prophylactic measures, I feel, are justified and rational, along with previous CS code. What is your openion

Thank you.


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