Ob-Gyn Coding Alert

Question: A patient presents with a complication from a previous surgery which was a laparoscopy with lysis of endometriotic lesions (Laparoscopy with Omnicell laser ablation of endometriosis) and now has hemoperitoneum bleeding. Should I use CPT^® code 58662 or use an unlisted code for this procedure? I know I would append modifier 78 with the diagnosis of 998.11 with 568.81.

The pertinent parts from the operative report are as follows:

Surgery: Laparoscopy with fulguration of bleeding

Indications: The patient is a 22 year old female postop day # 3 of laparoscopy with abdominal pain and hemoperitoneum on CT.

Findings: Bleeder without evidence of injury to the anterior uterus.  Multiple peritoneal bleeders outside of surgical field and possible bleeding on liver but general surgery consult - just watch.

Procedure Details: After induction of general anesthesia and initiating the insertion of the laparoscope and ports, approximately 600cc blood was visible on arrival into abdomen the abdomen was copiously irrigated to get all of the blood out of the surgical field.  The bleeding area on the uterus was noted and a Maryland was used to cauterize a small 1cm area to adequate hemostasis. Two areas of peritoneum up by the appendix were grasp tented and cauterized. The blood that was noted up by the liver was irrigated and suctioned and watched closely. General surgeon on call consulted and advised that it look hemostatic at the time of arrival. Pressure was then let out of the abdomen and then reinsufflated no new bleeding are as noted. All uterus, ovaries and pelvis along with all peritoneum were noted to be hemostatic. The abdomen was then copiously irrigated again with normal saline and all sites noted to be hemostatic.  Following the procedure all instruments were removed after intra-abdominal carbon dioxide was expressed. The incision was closed with both 4-0 Monocryl and Dermabond. The sponge stick was then removed.

California Subscriber

Answer: In this case, you should only be billing 49322-78 (Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple); 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).

While he also did a minor stitch on the uterus, most payers are going to consider this to be incidental and the primary reason for the surgery was to evacuate the blood in the abdominal cavity. Also, you cannot report 568.81 (Hemoperitoneum (nontraumatic)), as this was traumatic bleeding due to the previous surgical procedure. Just report the 998.11 (Hemorrhage complicating a procedure). In ICD-10, 998.11 becomes N99.820 (Postprocedural hemorrhage and hematoma of a genitourinary system organ or structure following a genitourinary system procedure).