Ob-Gyn Coding Alert

You Be the Coder:

Postoperative Seroma Visit

Published on Thu Aug 07, 2014

Question: Patient presented for cesarean delivery check 11 days postpartum to the midwife. The night prior to visit she developed fever, pain, and hard knots under the incision. She took ibuprofen and feels fever will return when it’s time to take the next dose. Exam of abdomen: nontender to palpation except at incision site, incision with Mefix still on but removed, erythema around left 2/3 incision, no drainage, streaking. Normal bowel sounds, tone normal without rigidity or guarding, no masses present. Uterine fundus not tender. The doctor was called in to confirm and states it appears she is developing an infection. The diagnosis is Infected post operative seroma. She is given Augumentin and Percocet. Expect improvement after 24 hours, to call if no improvement.

I know that some visits are easy; some are hard. With the info that I submitted, is this is visit billable?

California Subscriber

Answer: You should bill this with an E/M code (99212-99215, (Office or other outpatient visit for the evaluation and management of an established patient ...) with a modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) because this is an unexpected complication of the cesarean and the provider has documented a separate and significant evaluation of the complication.

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Question: Patient presented for cesarean delivery check 11 days postpartum to the midwife. The night prior [...]

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