Ob-Gyn Coding Alert

Question: Patient is about 4 weeks postpartum and comes in complaining of pain at episiotomy site. Exam shows a very slight separation of episiotomy. The ob-gyn recommends sitz baths. Can we bill an office visit or is this considered global?

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Answer: Most experts suggest you should consider this global, as this is not a significant complication. However, if your physician disagrees and wants you to code the visit, you can bill an E/M code (99201-99215, Office or other outpatient visit …). Link it to 674.24 (Disruption of obstetrical perineal wound postpartum) and see what happens. In ICD-10, this diagnosis will be O90.1 (Disruption of perineal obstetric wound).

You can’t append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to this E/M service, however, because the problem is 1) related to recovery from delivery, and 2) not a significant unexpected complication (CPT®’s clarification about when to use 24 for a related problem).