Ob-Gyn Coding Alert

Question: One of our doctors was consulted at the end of a c-section on a patient to perform a “Repair of incidental cystotomy and infusion of sterile milk post reapproximation.”

Description of Operation: The patient was already on the operating room table. Inspection of the abdomen and pelvis revealed complete adhesions of the pelvic organs to the anterior abdominal wall and a 2.5cm cystotomy. A running suture of 3-0 Vicryl followed by a second imbricating suture of 3-0 Vicryl was placed. Sterile milk was instilled in the bladder and demonstrated no evidence of leakage. There was a considerable oozing in the pelvis. The bladder had been dissected free of the uterine wall, but the space of Retzius had been dissected as well. There was some oozing in this area, and Floseal was applied to the surface of the reapproximation.

How should I code this? The doctor performing the c-section is not part of our practice.

Montana Subscriber

Answer: You should use code 51860 (Cystorrhaphy, suture of bladder wound, injury or rupture; simple) as this is simple bladder repair. The milk infusion was checking their work and not separately reportable.