Ob-Gyn Coding Alert

Question: My ob-gyn did a vaginal delivery (59400) only to take the patient back to the operating room to repair the uterine cervix (57720). Is there a CCI edit bundling these two codes? If so, can I use a modifier to bypass it?

Kentucky Subscriber

Answer: No, you won't find a Correct Coding Initiative (CCI) edit for this code combination.

You will tack on modifier 78 (Return to the operating room for a related procedure during the postoperative period) to the uterine cervix repair code (57720, Trachelorrhaphy, plastic repair of uterine cervix, vaginal approach), however, because he is taking her back to the operating room.

If the cervix repair took place at the time of the delivery and before the patient went to the recovery room, you would add modifier 51 (Multiple procedures) instead.

The reason is that the same physician is performing more than one procedure during the same session, and the second service is not a component of the first. Be sure to append this modifier (either 78 or 51) to the code with the lower relative value. Otherwise, you could lose out on legitimate reimbursement.

Don't forget to link 57220 to a cervical laceration diagnosis (665.31). But only report this if the physician documented it in the medical record.

-- The answers for Reader Questions and You Be the Coder were provided by Melanie Witt, RN, CPC-OGS, MA, an ob-gyn coding expert based in Guadalupita, N.M.