Ob-Gyn Coding Alert

Question: My ob-gyn had a weekend call. Patient had a laparoscopic supracervical hysterectomy (58541) by a physician we share call with. She presented to ER with vaginal bleeding, DVT and PE one week post op. Our physician was on call that weekend. He did initial visit that Saturday (consult through ER) and saw her on Sunday. She is a personal friend to our physician that was on call. Her regular ob-gyn was out of town, and so she continued with our practice. Our doctor that saw her over weekend (her personal friend) passed the case to his partner for her surgery on that Monday. She had an exam under anesthesia with repair to vaginal cuff. I am going to code this with 57410 and 57200. I am not sure what modifier I should use. Or should I use 13160?

Alabama subscriber

Answer: As this was a surgical complication, you will be using a 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).

Red flag: That said, you should consider the exam under anesthesia (EUA) as bundled-- it's always bundled.

You can bill the repair of the vaginal cuff using 58999 (Unlisted procedure, female genital system [nonobstetrical]) and compare the work to 57200 (Colporrhaphy, suture of injury of vagina [nonobstetrical]). Explain this was surgical wound dehiscence, not an injury.

You would not report 13160 (Secondary closure of surgical wound or dehiscence, extensive or complicated), because this is for integument, not the vaginal canal. Also, this procedure would not be complicated either.

Finally, your diagnosis code will be T81.31xA (Disruption of external operation [surgical] wound, not elsewhere classified, initial encounter).