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Ob-Gyn Coding Alert

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Apply Modifier 78 For Delivery and Same-Day Surgery

Published on Tue Mar 23, 2010

Question: The patient delivered on the same day as the following surgery: PREOPERATIVE DIAGNOSIS: Postpartum hemorrhage. POSTOPERATIVE DIAGNOSES: Postpartum hemorrhage with a large amount of clots in the uterus, as well as cervical laceration. OPERATIONS: 1. Exam under anesthesia. 2. Dilation and curettage (D&C) under ultrasound guidance. 3. Repair of cervical laceration. 4. Reapproximation of original vaginal laceration. 5. Repair of small new vaginal laceration due to speculum placement. In the full op report, the ob-gyn stated he examined the original laceration and found it to be intact. How should I report this? Georgia Subscriber Answer: You should report 57720-78 (Trachelorrhaphy,plastic repair of uterine cervix, vaginal approach; Unplanned return to the operating/ procedure room by the same physician following an initial procedure for a related procedure during the postoperative period) and 59160-51-78 (Curettage, postpartum; Multiple procedures). You can also bill for the ultrasound guidance (76998, Ultrasonic guidance, intraoperative) without a [...]
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