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 room, a minor treatment room, recovery room, or intensive care unit.

There are other circumstances in which a related procedure would need to be performed during the postoperative period of the first surgical procedure performed.

Note: Be sure to append -78 to the related procedure (not to the original surgery).

Dont Confuse Modifier -79 with -78

Its easy to confuse modifiers -78 and -79 (unrelated procedure or service by the same physician during the postoverative period). Both unbundle the subsequent procedure from the global period of the first surgical procedure so it can be paid; however, using the wrong one can result in a longer global period for the primary procedure.

Heres why: When you append modifier -78, a new postoperative period does not begin with that related procedure. Therefore, another 90 days is not added to the global period. (Its a good idea to monitor this fact to make sure carriers are honoring it.)

For example, if a patient requires a return to surgery for a related problem 75 days after a surgery with a 90-day global period, there are 15 days left on the global period. The carrier should not be denying E/M services after those days have passed. But when you append -79, a new postoperative period begins.

Dont give away E/M services when you dont have to, urges Susan Callaway-Stradley, CPC, an independent coding consultant who was recently named the American Academy of Professional Coders coder of the year.

So when do you use modifier -79? Suppose a patient had a vaginal hysterectomy, but during the 90-day global she develops an ovarian cyst that requires surgery. You would append -79 to the appropriate procedure code because the cysts are unrelated to the original procedure of a vaginal hysterectomy.

Note: Keeping modifiers -76 (repeat procedure by same physician) and -78 (return to the operating room for a related procedure during the postoperative period) straight is also important. For example, failure to use modifier -78 may result in a denial of a subsequent surgery. If you dont use -76, payers may think youve billed the original procedure twice and deny the subsequent one. Append modifier -76 when the ob-gyn performs the same procedure at a different time. To establish medical necessity, youll need to justify the second procedure. Be prepared to submit the operative report.

Coding for Postop Severe Pain

In the previous scenario (in which the woman had a vaginal hysterectomy for complete uterine prolapse and two hours later bleeding was noted but no source was found but the woman returned to the office two weeks later complaining of severe abdominal pain) the visit for the severe abdominal pain postoperatively is considered a postop complication and can be coded separately from the CPT global surgical package. As the office visit resulted in admission to the hospital with surgery performed on the same day, only a hospital admission code (99222-99223) can be reported, but a modifier -25 (significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) would need to be added to the hospital admit code to indicate a significant and separately identifiable E/M service took place on the day the decision to perform surgery was made, Witt says. The diagnosis codes justifying the E/M service would be 789.3x (abdominal or pelvic swelling, mass, or lump) and 789.6x (abdominal tenderness).

Note: Modifier -57 (decision for surgery) might also be accepted by some payers instead of -25, but modifier -57 was developed by Medicare to report the decision to perform major surgery, not minor surgery, and the code that will be reported in this example, 10140* (I&D of hematoma), is both a CPT starred procedure and one that has a Medicare 10-day global period. Under either set of rules, therefore, the procedure is considered minor surgery. Note that once again, modifier -78 (return to the operating room for a related procedure during the postoperative period) would need to be added to the surgery code. The diagnosis would still be 998.12 (hematoma complicating a procedure).