Ob-Gyn Coding Alert

Question: We have a patient that delivered by C/S on 07/13/16. She went to the ER on 07/21/16 for an infection at the incision site. At the ER, it was drained and packed. She was started on meds by the ER doctor. She was seen in our office on 07/22/16 for follow-up. A culture was obtained, and the wound was probed, cleaned, irrigated and repacked. The physician documented erythema and induration along R half of the incision. She was told to return on 07/25/16. On 07/25/16, the notes states, “incision looks good, 3cm area is opened with packing in, removed and repacked, no purulent drainage, no erythema.” The provider states, “Looks good, incision repacked.” She wants to bill a 99213. Wouldn’t this be a postpartum visit? It is not a significant complication. It is healing, correct?

California Subscriber

Answer: You should consider this to be routine care of the cesarean wound, which is included in the care after a cesarean. You can bill for the 7/22 visit separately as this was a complication (99211-99213,Office or outpatient visit for an established patient …), but on 7/25, you should consider this to be part of the routine wound check.