Ob-Gyn Coding Alert

Ob/gyns often run into situations where a patient will have to be returned to the operating room following a previous procedure. Coding for this situation can be difficult as both the initial procedure and the return to the OR need to be correctly coded.

The Scenario: A 52-year-old woman had a vaginal hysterectomy for complete uterine prolapse. Two hours following surgery, bleeding was noted and an extraperitoneal hematoma was suspected. The patient was taken back to the operating room where an exploratory laparotomy and inspection of the vaginal cuff was performed. The laparotomy did not reveal a source for the bleeding, however.

The patient went home a few days later, but returned two weeks later to the office complaining of severe abdominal pain. An exam showed tenderness and a lump just under the skin of the abdominal incision. A subcutaneous hematoma was suspected, and the patient was admitted to the hospital and taken to surgery this same day. The hematoma was incised and drained, the postoperative recovery from the procedure was uneventful, and the patient was discharged home on the fifth day.

Use -78 Modifier During Global

Coding Initial OR Procedure: The original procedure of a vaginal hysterectomy was coded 58260 (vaginal hysterectomy), because the tubes and ovaries were left in place, explains Melanie Witt, RN, CPC, MA, program manager for the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists (ACOG). This procedure code should be linked to either 618.1 (uterine prolapse without mention of vaginal wall prolapse) or 618.3 (complete uterovaginal prolapse). The choice of diagnosis code will depend on the information supplied by the physician or additional information contained in the operative report.

Coding Return to OR: To report the return to the operating room, a modifier will have to be added to the surgical code to show that it was either a related or unrelated procedure during the postoperative period, Witt says. In this case, modifier -78 (return to the operating room for a related procedure during the postoperative period) would be appropriate because the bleeding was related to the surgery. This modifier will be added to the surgical code for an exploratory laparotomy (49000). Note that code 49002 (reopening of recent laparotomy) would not be correct to report in this case because, although this was an exploration of post-op hemorrhage, a previous laparotomy had not been performed. The diagnosis is 998.11 (procedure complicated by hemorrhage) and/or 998.12 (procedure complicated by hematoma).

Append -78 when the subsequent procedure is related tobut not the same asthe original procedure and it requires a trip to the operating room.

Note: An operating room means exactly thata surgical, laser, or endoscopic suitenot the patients [...]