breyes
New
Coding help please. This is a completely new situation for me: I have a CNM that billed out for a 59400. An OB (not part of our group) performed a repair at the time of delivery. 8 Days post-partum, the patient was seen in our office by the delivering CNM. CNM notes: "Vagina - 2 cm reopening of vaginal tear @ introitus extending approximately 3 cm deep into vaginal vault. Two areas of suture visible. Site of reopening has increased bleeding." Treatment: "Vaginal Lac was repaired w/2.0 in the usual fashion" I think I have a couple issues. Currently, the provider has this DX as O70.1. I am thinking that we will need to include some sort of postprocedural complication dx. Regarding the actual repair - I'm pretty sure this is billable even though she was the delivering provider (but not positive). Do I look at laceration repairs (12001) or do I look at 59300? I'm also looking at modifiers. This was an unplanned procedure during the global period. Would 78 be appropriate (procedure room in clinic not hospital OR). So many questions on this one. I look forward to your input.