Ob-Gyn Coding Alert

Question: The ob-gyn performed a LAVH with BSO (uterine weight of 270 grams); the hysterectomy was completed laparoscopically; during inspection prior to closing the patient, he noted an area of bleeding just below the uterine pedicle. His attempt to secure this area of bleeding with a clip as well as two separate Endoloops was without success, and the bleeding became more brisk. At that point, he converted the procedure to an exploratory laparotomy. He located the area of bleeding on the right pedicle; he then grasped this area with an Allis clamp and placed three separate 0 Vicryl figure-of-eight sutures with excellent hemostasis. After more inspection and irrigation, he noted no additional bleeding and closed the patient. Later on the same day, during post op rounds, the patient had to go back to the OR on an emergent basis due to a large hematoma discovered on ultrasound. He performed an exploratory laparotomy with evacuation of hematoma and blood clot and ligation of rectus muscle arterial bleeder.

How should I code these surgeries? Should I code the initial surgery with the laparoscopic codes since the hysterectomy was completed prior to converting to a laparotomy? Also, I am not familiar with the ligation of vessel and artery codes. Any help or will be greatly appreciated.

New York Subscriber

Answer: Because the only service the ob-gyn provided after the conversion was a control of bleeding, you should code this with the 58554 (Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube[s] and/or ovary[s]) and perhaps add a modifier 22 (Increased procedural service). Keep in mind that payers consider control of bleeding as integral to every procedure. Some are easy, and some are hard, so you should not count on extra payment.

For the return, you are now opening an abdominal incision, so you should go with 35840-78 (Exploration for postoperative hemorrhage, thrombosis or infection; abdomen; Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period). You should report this code because the physician did do a ligation of an artery.

Watch out: You should not submit 49002 (Reopening of recent laparotomy) because your first code is laparoscopic. This might lead to a first time denial because it does not match the original procedure.