Ob-Gyn Coding Alert

Reader Questions:

What to Do When CNM Bills Global and OB Performs a Repair

Question: 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)?

Florida Subscriber

Answer: You should call this a complication of wound dehiscence, which would lead you to 12020 (Treatment of superficial wound dehiscence; simple closure) with the tear in a mucous membrane that is easily accessed. Including modifier 78 (Unplanned Return to the operating/Procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) to report unplanned seems appropriate given the complication of wound dehiscence.

Using O70.1 (Second degree perineal laceration during delivery) is not right this in this instance, since the wound was already addressed at the delivery. You should use O90.1 (Disruption of perineal obstetric wound) instead.