Op Note Coding:
Battle Your Way through This Post-Delivery Laceration and Hemorrhage Scenario
Published on Tue Nov 24, 2009
15+% depends on whether you call an evacuation a complication or surgery portion. 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, [...]
