Ob-Gyn Coding Alert

Question: A day after an operation, a patient presented to our office. The ob-gyn documented "Open incision in umbilicus. 5-mm defect noted, stitch placed with 4-0 vicryl after injecting with lidocaine." Would this service be included in the global period?


Minnesota Subscriber

Answer: No. If your ob-gyn considers the open incision to be wound dehiscence, you should use 12020 (Treatment of superficial wound dehiscence; simple closure). Another option might be 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) if the ob-gyn noted that this was a defect after the surgery and was not due to wound dehiscence.

You should not append modifier -78 (Return to the operating room for a related procedure during the postoperative period) in this circumstance, because she was not taken back to the operating room. However, you might be able to use this modifier if this condition truly is a defect and not a direct result of the surgery. Be prepared to argue the point with some payers.

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