Ob-Gyn Coding Alert

Avoid denials and accidentally reducing the allowable fee on multiple services by testing your modifier 51 versus modifier 78 savvy with this complicated ob op note.

First, Read the Op Note Preoperative/Postoperative diagnosis: Postpartum hemorrhage with uterine atony, hematoma of vaginal sidewall.

Procedure Performed: Evacuation of hematomas and repair of vaginal laceration.

Operation: The patient was taken to the operating room after working with the patient for 30-45 minutes back in the delivery room with the anesthesia and nurses. She had significant uterine atony after a vaginal delivery and lost at least 1,000 cc of blood after the 400 cc of blood loss that occurred during the delivery. Upon arrival, she was sitting in a large pool of blood, estimated at least 1,000 cc.

Her uterus was atonic. Vigorous uterine massage was carried out with Pitocin infusion, stepped up to 60 international units per liter, rushing it in as fast as we could. A second IV was started. Methergine was given, Cytotec rectally and Hemabate IM.

Vigorous uterine massage was carried out throughout that time. Her uterus clamped down after I evacuated the blood clots which were part of the 1000 cc. After she was stabilized, however, vaginal bleeding continued. She was placed in stirrups and exploration of the vagina was carried out and a hematoma was noted in the right upper vaginal sidewall which could not be reached from the delivery room. She was taken back to the operating room after risks, benefits, and alternatives were discussed. She was placed in the dorsal lithotomy position and examined carefully. A large hematoma approximately 2.5 x 2.5 sq. cm. was noted in the upper right vaginal sidewall and, by this time, there was some bleeding through a laceration in the mucosa. Evacuation of blood clot was carried out and deep sutures of 2-0 Vicryl were placed in an interrupted fashion, approximately 5 sutures. The laceration continued down and slightly lower into the vaginal canal. Several interrupted 2-0 Vicryl sutures were placed. Eventually all the bleeding stopped.

Vigorous uterine massage was carried out when she was asleep and her uterus had clamped down nicely. Total estimated blood loss is approximately 1,500 cc with the delivery as well as uterine atony. Transported to the recovery room in stable condition. Transfusing blood 2 units.

In this note, you have a delivery and you know you will either bill a global or delivery ob code -- but that doesn't mean your coding is cut and dry. Ask yourself the following questions:

• Did the ob-gyn perform and document postpartum curettage? No. "The ob-gyn did not discuss the curettage, only the removal of clots and uterine massage," says Harry Stuber, MD, an independent obgyn in Cookeville, Tenn., and co-presenter of the "Ob-Gyn Op Notes" session at the 2009 National Ob-Gyn Coding & Reimbursement Conference in Orlando.

• Can you code the repair of the laceration? Not with the available information. You should include the repair of a first or second degree laceration with the delivery. From the documentation, you can discern she has a large hematoma that the ob-gyn removed from the vaginal canal. After this, the ob-gyn placed sutures. What you don't know is the extent of the vaginal laceration he mentions (its total length), Stuber points out. Nor is it clear whether the physician did a simple or intermediate repair of the extended laceration. In other words, you will have to go back to your ob-gyn for more information.

• What modifier should you append on the vaginal hematoma evacuation? This documentation does not explain whether the ob-gyn returned the patient to the operating room (OR) for the hematoma procedure, or if this was simply a continuation of the delivery. Given the information you have, that is unknown. Again, you should ask your ob-gyn for clarification.

Answering these questions will lead to the best coding solution. You have two options:

You can submit the global code 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy and/or forceps] and postpartum care) with modifier 22 (Increased procedural services) appended, says Peggy Stilley, CPC, CPC-I, COBGC, ACS-OB, clinic manager for the University of Oklahoma in Tulsa and co-presenter of the "Ob-Gyn Op Notes" session at the conference.

Your diagnosis codes will be 666.12 (Postpartum hemorrhage; other immediate postpartum hemorrhage; delivered, with mention of postpartum complication) and 665.71 (Other obstetrical trauma; pelvic hematoma; delivered, with or without mention of antepartum).

Action: Include the operative report and a letter explaining why the procedure was more complicated than a normal delivery.

You can cross out the need for modifier 22 by itemizing each of the ob-gyn's services in addition to the global delivery. For the removal of the clots and uterine massage, you would report 59899 (Unlisted procedure, maternity care and delivery) with modifier 51 (Multiple procedures). Keep in mind many payers no longer require modifier 51. Processing claims electronically allows the payer to recognize when your physician performs multiple procedures and automatically makes the necessary reduction in payment. Check with your payer to see if you need to use modifier 51 when your ob-gyn performs more than one procedure in a session.

Tip: You would link this to 666.12, but you would need to let the payer know the amount of work involved for this portion of the care. You may not use the prolonged physician codes since you're not reporting an E/M service, but you can tell the payer that the uterine massage took 40 minutes and compare the work to code 99356 (Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour).

Then you would report 57022 (Incision and drainage of vaginal hematoma; obstetrical/postpartum) linked to 665.71. This procedure includes the closure of the wound.

Modifier issue: When deciding what modifier to append to 57022, you have to decide whether this surgery qualifies as a return to the operation room. If so, you can apply modifier 78 (Unplanned return to the operating/procedure room by the same physician following an initial procedure for a related procedure during the postoperative period). "This implies the patient was taken out of the OR to a recovery room and then unexpectedly had to return to the OR," Stilley says.

When you're filing claims with modifier 78, you shouldn't expect to receive the full fee schedule reimbursement amount. Procedures billed with modifier 78 include only the service's "intraoperative" portion, and carriers generally reimburse them at 65-80 percent of the full fee schedule value, says Patrice Young, CPC, CMSCS, with a private practice in Pennsylvania. In other words, if you report a procedure with modifier 78, you will not receive the portion of payment assigned to the pre- and post-operative care usually associated with that procedure.

If this surgery does not qualify for modifier 78, you would apply modifier 51 if your payer requires it. This will reduce your reimbursement for this procedure by a full 50 percent.

To request a CD of this year's Ob-Gyn Coding & Reimbursement conference, go to www.codingconferences.com or call 1-866-251-3060.