Ob-Gyn Coding Alert

Question: One day after the patient had a vaginal hysterectomy, she went back into surgery for postoperative bleeding with extraperitoneal hematoma. During this surgery, the physician did a laparotomy to close a bleed on the left lower angle of the cuff. How should I report the laparotomy?


South Carolina Subscriber

Answer: First, your diagnosis should be 998.11 (Hemorrhage complicating a procedure).

As for CPT, you should report 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]) with modifier 78 (Return to the operating room for a related procedure during the postoperative period) for the exploratory procedure.

Heads up: You won't find a code for suturing the vaginal cuff via the abdominal incision. If your ob-gyn had gone in via the vagina to suture the cuff, you could use 58999 (Unlisted procedure, female genital system [nonobstetrical]). In that case, you would also need to submit your op report along with a cover letter that explains in simple, straightforward language exactly what your ob-gyn did. Remember to explicitly reference the nearest equivalent listed procedure in your explanatory note. Your closest option would be the code for repair of a vaginal injury, 57200 (Colporrhaphy, suture of injury of vagina [nonobstetrical]).

Note: You should not report 49000-78 and 58999-78-51 (Multiple procedures) and expect to receive reimbursement for both. The reason is your question indicates the repair occurred via the abdominal incision.