Wiki postop hemorrhage while in the o.r. Help??

[kimcpccircc]

I have a patient that had a carotid endarterectomy (35301) performed and incision was closed.

Then, while still in the o.r., as they were waking the patient, she developed a large hematoma and they reopened the incision, evacuated the clot and had to suture repair a leak in the graft.

Do I charge the direct repair neck with a modifier 59? (35201)

I know there is debate on return to surgery same day, but this patient didn't make it out of the o.r.

Would appreciate any help!! Thanks

 

[jewlz0879]

It is my understanding that if they did not leave the O.R. you could not bill for it but if they have left the O.R. and come back, then you can bill with a 78. I'm honestly not sure where to find this direction or a link that backs it up. If someone knows, please let us know. Or if I'm mistaken, please correct me. I do not mind constructive criticism.

 

[helencombs]

According to what I found here: http://www.sts.org/sites/default/files/documents/pdf/STSCodingNews-Summer2004.pdf

it is billable as it is in the same operative session. see pg 3, right hand column. Or at least the way I read it.

 

[ABridges]

Yes, you should bill for the repair.

The determination is not whether or not they have left the OR, it is whether on not the surgical site has been closed and has to be re-opened.

Without seeing the actual OP note it is difficult to say which code you should use, but I would look at 35800 as a possibility.

Hope that helps!