Ob-Gyn Coding Alert

Question: I have a patient that had a uterine inversion after a vaginal delivery. The patient underwent a diagnostic laparotomy to confirm the diagnosis of uterine inversion. At that point, the doctor proceeded to manually invert the uterus using downward counterpressure. Once inverted the uterus was extremely flaccid and did not contract despite the use of Pitocin, Methergine, and Prostoglandins. A Bakri Intrauterine balloon was inserted to fundus and inflated to keep uterus in place. The patient also underwent a sulcus and episiotomy repair. What code(s) and modifiers should I use?

Florida Subscriber

Answer: There is no code for inversion of the uterus, and this was clearly a laparotomy. So your best bet is 49000 (Exploratorylaparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]) for this part of the surgery unless you want to bill an unlisted code, which I would not advise.

The Bakri balloon is unlisted (59899, Unlisted procedure, maternity care and delivery). Your comparison codes for the payer might be 43460 (Esophagogastric tamponade, with balloon [Sengstaken type]) with 6.26 RVUs, 46604 (Anoscopy; with dilation [eg, balloon, guide wire, bougie]) with 1.93 RVUs, or 51703 (Insertion of temporary indwelling bladder catheter; complicated [eg, altered anatomy, fractured catheter/balloon]) with 2.22 RVUs. The provider needs to decide which of these codes is closest to the work he/she performed, not you as the coder.

As for the repair, an episiotomy is always bundled into the delivery, but you might get paid for the sulcus tear. A sulcus tear is one of the vaginal canal, and the code 57200 (Colporrhaphy, suture of injury of vagina [nonobstetrical]) would seem ideal, but it is only for a non-ob related injury. So once again, this would be an unlisted procedure (59899) with the comparison to 57200.

Since you should not list 59899 twice on the claim, bill it once, and send in documentation noting the comparison codes and a complete description of the work. And don't forget the modifier 78 (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).

So 49000-78, 59899-78 with documentation would be your best bet for this scenario.