wfriddle
Networker
I have a case were the doctor had to take a patient back to the operating room after an anterior colporrhaphy due to bleeding. I can not for the life of me figure out what code to use. I know I can bill it with modifier 78 but can decide what the most accurate code is for the repair. Please help!!! The op report...
PREOPERATIVE DIAGNOSIS:
Postoperative vaginal bleeding.
POSTOPERATIVE DIAGNOSIS:
Postoperative bleeding from anterior colporrhaphy site.
NAME OF OPERATION:
Examination under anesthesia.
Inspection of anterior colporrhaphy site with identification of bleeders and ligation of same, and resuture of anterior
vaginal wall.
SURGEON:
SURGICAL TECHNIQUES:
With the patient in the lithotomy position under general anesthesia, she was prepped and draped. A Bakri balloon
had been placed for compression in the vaginal vault. This was removed. Attention was directed to the anterior
vaginal wall. Retractors were placed. The vaginal cuff was carefully examined, found to be intact. There was no
evidence of active bleeding. Likewise, the posterior vaginal incision sites were also carefully inspected and found to
be intact with no bleeding. While there was no gross bleeding anteriorly, there was distension of the cystocele
incision. Therefore, the interrupted sutures holding the anterior vaginal mucosa together were excised and the
anterior vaginal incision was opened. Blood and clots were expressed and bleeding sites were found laterally on the
right and left with the right being more predominate. Figure-of-eight sutures were used to obtain complete
hemostasis. The site was irrigated with saline and observed for an extended period of time to ensure that all bleeding
sites had been identified and ligated. After ensuring that the surgical bed was dry, the vaginal mucosa was then
reapproximated with interrupted suture of double-0 Vicryl. All areas were again reinspected, found to be hemostatic.
Instruments and sponges were then removed and the patient was sent to the recovery room in good postoperative
condition.
GROSS FINDINGS:
The patient had a postoperative bleeder beneath the mucosa of the anterior vaginal incision which was the part of her
previous cystocele repair.
I can't decide if a repair code would be appropriate like 12031. Any guidance would be much appreciated.
PREOPERATIVE DIAGNOSIS:
Postoperative vaginal bleeding.
POSTOPERATIVE DIAGNOSIS:
Postoperative bleeding from anterior colporrhaphy site.
NAME OF OPERATION:
Examination under anesthesia.
Inspection of anterior colporrhaphy site with identification of bleeders and ligation of same, and resuture of anterior
vaginal wall.
SURGEON:
SURGICAL TECHNIQUES:
With the patient in the lithotomy position under general anesthesia, she was prepped and draped. A Bakri balloon
had been placed for compression in the vaginal vault. This was removed. Attention was directed to the anterior
vaginal wall. Retractors were placed. The vaginal cuff was carefully examined, found to be intact. There was no
evidence of active bleeding. Likewise, the posterior vaginal incision sites were also carefully inspected and found to
be intact with no bleeding. While there was no gross bleeding anteriorly, there was distension of the cystocele
incision. Therefore, the interrupted sutures holding the anterior vaginal mucosa together were excised and the
anterior vaginal incision was opened. Blood and clots were expressed and bleeding sites were found laterally on the
right and left with the right being more predominate. Figure-of-eight sutures were used to obtain complete
hemostasis. The site was irrigated with saline and observed for an extended period of time to ensure that all bleeding
sites had been identified and ligated. After ensuring that the surgical bed was dry, the vaginal mucosa was then
reapproximated with interrupted suture of double-0 Vicryl. All areas were again reinspected, found to be hemostatic.
Instruments and sponges were then removed and the patient was sent to the recovery room in good postoperative
condition.
GROSS FINDINGS:
The patient had a postoperative bleeder beneath the mucosa of the anterior vaginal incision which was the part of her
previous cystocele repair.
I can't decide if a repair code would be appropriate like 12031. Any guidance would be much appreciated.