Ob-Gyn Coding Alert

You Be the Coder:

Repeat C-Section With Pelvic Adhesions

Question: How would I code for a repeat global c-section, T incision on uterus? I assume 59510 as I can’t find anything different.

Is there an ICD-10 diagnosis code I should use to show this was done? I found ICD-10 for history of T incision (O34.218), but not one for this case. So I know I would use O34.211 for the previous c-section.

Also, the patient had adhesions, and that’s why the ob-gyn had to do the T incision. Note states, “dense adhesions of the bladder to the lower uterine segment made it not possible to grasp the uterine visceral peritoneum. Therefore, I made my uterine incision above the area of the adhesions... I was unable to guide the head through the incision, I teed to the incision in the midline. I then used the kiwi vacuum to help guide the head out of the incision....”

What should I report?

New Mexico Subscriber

Answer: First, you should report CPT® code 59510 (Routine obstetric care including antepartum care, cesarean delivery, and postpartum care), if your ob-gyn provided all the prenatal care and is planning to see the patient for her postpartum care.

As for your diagnosis codes, you should reflect why the ob-gyn is performing the c-section. Was it a repeat T-incision c-section? Or was there some other pressing reason for the cesarean, such as a breech position or fetal distress? Do you know if this was this a failed induction? You would not report O34.211 (Maternal care for low transverse scar from previous cesarean delivery) unless the previous cesarean was performed via a low transverse incision. To find that out, you may have to dig into her history or consult with the provider. If the previous cesarean was performed with a normal incision, you would report O34.212 (Maternal care for vertical scar from previous cesarean delivery).

Remember, you can only link four diagnosis codes to a charge, so you could report an O34 code, N73.6 (Female pelvic peritoneal adhesions (postinfective)), then the patient’s weeks of gestation, and then the outcome of birth. That being said, you can find a diagnosis that pertains more to the entire pregnancy or reason for the c-section, you should report that in place of N73.6.