Ob-Gyn Coding Alert

Question: A patient was taken to the operating room postdelivery to repair a vaginal sulcus tear and given an epidural. Can I bill for any additional service outside of the global package?

Michigan Subscriber
 
     
Answer: If the obstetrical physician performed the delivery, the repair is normally included in the global package.
 
If the ob/gyn performed the delivery but did not do an episiotomy repair post-delivery and the tear was found later, the repair may still be considered part of the global package.
 
If the physician who performed the delivery did an episiotomy repair that tore afterward (requiring a return to the operating room), the diagnosis is wound breakdown (674.2x, Disruption of perineal wound), and you can bill for a repair code that indicates genitalia.)
 
The choices are 12001-12007 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet] ), 12041-12047 (Layer closure of wounds of neck, hands, feet and/or external genitalia ) for intermediate repair, or 13131-13133 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet ) for complex repair.
 
The code you select would be appended with modifier -78 (Return to the operating room for a related procedure during the postoperative period).
 
If your ob/gyn did not perform the delivery, you can code the repair 59300 (Episiotomy or vaginal repair, by other than attending physician) with 674.2x (if the physician who performed the delivery had done a previous repair) or 665.44 (High vaginal laceration; postpartum condition or complication) for a newly treated tear so long as there was also no mention of a perineal tear.
 
If the perineal tear was noted in the operative report from delivery, then the diagnosis code would come from the 664.xx category (Trauma to perineum and vulva during delivery).     You Be the Coder and Reader Questions were answered by Melanie Witt, RN, CPC, MA, an independent coding consultant and ob/gyn coding expert based in Fredericksburg, VA.