Ob-Gyn Coding Alert

Question: My ob-gyn performed an exploratory vaginal surgery. The patient was status post normal spontaneous vaginal delivery with continuous vaginal bleeding after a vaginal repair of laceration. The vaginal packing was in place. Should I report 57410 or 49000?

New Mexico Subscriber

Answer: This depends on the approach. You should report 57410 (Female pelvic examination under anesthesia) if the ob-gyn looked only at the vagina, and of course this procedure means it was a vaginal approach. Code 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]) is an open abdominal procedure.