Ob-Gyn Coding Alert

Question: Some of our physicians are lacking, I believe, in their documentation of BTL’s while performing a C/S, and I wanted to see if it’s necessary to document the step-by-step process of the procedure being done or if what is stated in this note is adequate:

“The uterus, tubes and ovaries appeared normal. The uterine incision was closed with running locked sutures of delayed absorbable suture in a double layered fashion. A bilateral modified pomeroy tubal ligation was then performed. Hemostasis was excellent. The peritoneum was closed with delayed absorbable suture.” So is this okay?

Nevada Subscriber

Answer: Surgeons who do not document the procedure they performed (in this case, the add-on code 58611 (Ligation or transection of fallopian tube[s] when done at the time of cesarean delivery or intra-abdominal surgery [not a separate procedure] [List separately in addition to code for primary procedure]) are at risk if something should go wrong later. Guess who they are going to believe in a malpractice suit if the patient then gets pregnant, but all the surgeon said was they did a modified Pomeroy?

While a clinical description of this procedure can be found in texts, variations of the Pomeroy tubal ligation technique include the length and location of the tied and cut tubal segment, number and type of ligatures placed around the tube, and whether the cut ends of the tube were also crushed or coagulated. These variations of the Pomeroy procedure determine the lengths of tubal segments remaining that can be repaired and if the patient later changed her mind and wanted a reversal, the op note would clearly indicate whether this would be possible.

A typical dictation might include the following: “A modified Pomeroy technique was completed with double tying of the left tube with 0 chromic, then upper portion was sharply incised and the cut fallopian tube edges were then cauterized. Adequate hemostasis was noted. This tube was placed back in its anatomic position. The right fallopian tube was grasped and followed to its fimbriated end and then regrasped with a Babcock and a modified Pomeroy technique was also completed on the right side, and upper portion was then sharply incised and the cut edges re-cauterized with adequate hemostasis and this was placed back in its anatomic position.”