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LTibbetts

LTibbetts

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I have a patient that came in for endometriosis and pelvic pain. She had a scheduled bilateral salpingo-oophorectomy and extremely extensive lysis of adhesions (per physican). During post-op, the patient went back to the OR for evacuation of a post-op hemoperitoneun and ligation of rectosigmoid mesentric bleeding. Without having both op notes to read, I was hoping that someone might be able to tell me if I am at least on the right track. Oh, and the patient was also being tranfused with blood during the second procedure as well. Will that be coded separately as well? I went with:

58661
58660-59
35840-78

Am I off track?
 
Hi Leslie - 58660 is inclusive to 58661 so it cannot be reported even with mod -59. If documentation supports the "extensive adhesions" I would use 58661-22. Your doc must document what was extensive about them and how much extra time it took to remove them.
 
Ok, thanks Lisa, and thanks for the quick reply. The documentation definitely supports the -22 so I'll add that. What about the other code? Was that right? And what about the transfusion that was given simultaneously, is it incidental to the procedure? I appreciate all of your help!!
 
Leslie - I'm not sure on the 3rd code, but it appears to be appropriate. Mod -78 would be the correct modifier. As far as the transfusion question - I don't think a physician can code for this since he/she is not performing it - it would be for the facility to code.
 
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