Ob-Gyn Coding Alert

Question: What diagnosis code should I use when the physician notes the Dx as “post ablation bleeding?” The patient underwent ablation in 2010, and now the patient is having a lot of bleeding.

Tennessee Subscriber

Answer: It will depend on what the physician has documented in support of the cause of the post ablation bleeding. You would report 998.11 (Hemorrhage complicating a procedure) if the patient’s bleeding relates directly to having performed the ablation.

However, bleeding not noted until two years later is unlikely to be due to performing the procedure. So find out what the physician suspects and most likely you will have to report 626.8 (Other disorders of menstruation and other abnormal bleeding from female genital tract) until the physician determines the most specific cause.

Watch out: Code 998.11 expands into more than 55 new codes. The new codes indicate whether the hemorrhage occurred during the operative session with the descriptors noting “Intraoperative hemorrhage and hematoma of ...” or after the procedure, with the wording “Postprocedural hemorrhage and hematoma of ....” The code 626.8 becomes N93.8 (Other specified abnormal uterine and vaginal bleeding).