Ob-Gyn Coding Alert

Question: The patient delivered on the same day as the following surgery:

PREOPERATIVE DIAGNOSIS: Postpartum hemorrhage.

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 modifier.

Heads up: You have indicated in the operative summary that the surgeon reapproximated the original vaginal laceration and repaired a small additional vaginal laceration. You may want to look again at the medical need for the reapproximation of the original laceration. You state that in the full operative report, this ob-gyn stated he examined the original and found it to be intact. That means you don't have medical need for this reapproximation. Also, the speculum placement caused a small additional laceration during this procedure, and as you don't say the ob-gyn documented the size of wound, you should assume an incidental repair and not code for it without much more information.

For the cervical laceration, you should report 665.31 (Laceration of cervix; delivered with or without mention of antepartum). For the postpartum hemorrhage, you'll report 666.12 (Postpartum hemorrhage; other immediate postpartum hemorrhage; delivered, with mention of postpartum complication).

ICD-10: In 2013, these codes become O71.3 (Obstetric laceration of cervix) and O72.1 (Other immediate postpartum hemorrhage).