debellis59
Networker
I hope you can help me with this. We had a patient who had a primary C-section complicated by hemorrhage. Pt was sent to ICU, the provider did see her there. I'm wondering if I can code for the ICU admit along with the C-section or just add mod 22? (Any help is appreciated) The edited note is as follows:
*Pre-Op Dx:
1) IUP at 39w5d
2) Fetal intolerance of labor, remote from delivery
3) GBS negative
*Post-Op Dx:
1) Same as above
2) Postpartum hemorrhage secondary to uterine atony
3) Hemorrhagic shock requiring blood transfusion and vasopressor support
*Procedure Performed: Primary cesarean section
*Findings:
1) Liveborn female infant with Apgars 4,8
2) Hemostatic hysterotomy at completion of procedure
3) Significant uterine atony and postpartum hemorrhage requiring IV pitocin, IV tranexamic acid, IM methergine, and PR misoprostol
4) Hematuria noted prior to procedure start
*Estimated Blood Loss: 3097mL
Operative Procedure:
Patient was taken back to the operating room. Epidural anesthesia was administered by the anesthesiologist without complication. Patient was positioned in supine position with a left lateral tilt. Foley catheter was already in place. Patient was prepped and draped in the usual sterile fashion. Time-out was performed. Anesthesia was tested and found to be adequate. Pfannenstiel incision was made sharply using scalpel. Subcutaneous tissue was sharply incised using the scalpel until the fascia was reached. The fascial incision was incised with the scalpel, and was extended bilaterally using the Joel-Cohen maneuver. The peritoneum was entered bluntly and incision was stretched bluntly. Alexis retractor was placed. Bladder was noted to be edematous and swollen, bladder flap was created. Incision made over lower uterine segment with the scalpel, uterine cavity was entered bluntly. No injury to the fetus was noted. Fetus noted to be in cephalic presentation. The fetal head delivered with Kiwi vacuum assist, followed by the remainder of the body without issue. Cord was doubly clamped and cut, and the neonate was given to the awaiting nursing team. Cord gases were obtained. Cord blood was obtained. Placenta delivered easily shortly after with uterine massage. Upon delivery of the placenta, brisk bleeding was noted from hysterotomy and uterine tone was boggy. Patient was given 1g of tranexamic acid. Hysterotomy was closed using 0-Vicryl in continuous running fashion, as well as a second imbricating layer. Arista placed as well. Excellent hemostasis noted. Excellent uterine tone noted as well. Fascia was closed in continuous running fashion using 1-0 Vicryl. Subcutaneous tissue was copiously irrigated. Subcutaneous tissue closed in continuous running fashion using Vicryl suture. Skin was closed in subcuticular fashion using 4-0 Monocryl. Steri-strips were placed, as well as island dressing. All instrument and sponge counts were correct at completion of the case.
Drapes were lifted, and extensive blood loss noted from the vagina underneath the patients legs. Uterus was expressed, and large clots were expelled. Manual evacuation of clots was performed as well. Uterus was noted to be boggy, and patient was given 200mcg of IM Methergine, as well as 1000mcg rectal misoprostol. Uterine tone improved, and bleeding improved significantly with the medication. At this time, patient was noted to be hypotensive and tachycardic, with concern for hemorrhagic shock. She was awake and alert throughout. Arterial line was placed by Dr. DePinto, see separate note for details. Patient was transfused 1 unit pRBCs. She was started on vasopressor support. At this time, decision was made to transfer patient to ICU for post-operative care and additional resuscitation.
*Pre-Op Dx:
1) IUP at 39w5d
2) Fetal intolerance of labor, remote from delivery
3) GBS negative
*Post-Op Dx:
1) Same as above
2) Postpartum hemorrhage secondary to uterine atony
3) Hemorrhagic shock requiring blood transfusion and vasopressor support
*Procedure Performed: Primary cesarean section
*Findings:
1) Liveborn female infant with Apgars 4,8
2) Hemostatic hysterotomy at completion of procedure
3) Significant uterine atony and postpartum hemorrhage requiring IV pitocin, IV tranexamic acid, IM methergine, and PR misoprostol
4) Hematuria noted prior to procedure start
*Estimated Blood Loss: 3097mL
Operative Procedure:
Patient was taken back to the operating room. Epidural anesthesia was administered by the anesthesiologist without complication. Patient was positioned in supine position with a left lateral tilt. Foley catheter was already in place. Patient was prepped and draped in the usual sterile fashion. Time-out was performed. Anesthesia was tested and found to be adequate. Pfannenstiel incision was made sharply using scalpel. Subcutaneous tissue was sharply incised using the scalpel until the fascia was reached. The fascial incision was incised with the scalpel, and was extended bilaterally using the Joel-Cohen maneuver. The peritoneum was entered bluntly and incision was stretched bluntly. Alexis retractor was placed. Bladder was noted to be edematous and swollen, bladder flap was created. Incision made over lower uterine segment with the scalpel, uterine cavity was entered bluntly. No injury to the fetus was noted. Fetus noted to be in cephalic presentation. The fetal head delivered with Kiwi vacuum assist, followed by the remainder of the body without issue. Cord was doubly clamped and cut, and the neonate was given to the awaiting nursing team. Cord gases were obtained. Cord blood was obtained. Placenta delivered easily shortly after with uterine massage. Upon delivery of the placenta, brisk bleeding was noted from hysterotomy and uterine tone was boggy. Patient was given 1g of tranexamic acid. Hysterotomy was closed using 0-Vicryl in continuous running fashion, as well as a second imbricating layer. Arista placed as well. Excellent hemostasis noted. Excellent uterine tone noted as well. Fascia was closed in continuous running fashion using 1-0 Vicryl. Subcutaneous tissue was copiously irrigated. Subcutaneous tissue closed in continuous running fashion using Vicryl suture. Skin was closed in subcuticular fashion using 4-0 Monocryl. Steri-strips were placed, as well as island dressing. All instrument and sponge counts were correct at completion of the case.
Drapes were lifted, and extensive blood loss noted from the vagina underneath the patients legs. Uterus was expressed, and large clots were expelled. Manual evacuation of clots was performed as well. Uterus was noted to be boggy, and patient was given 200mcg of IM Methergine, as well as 1000mcg rectal misoprostol. Uterine tone improved, and bleeding improved significantly with the medication. At this time, patient was noted to be hypotensive and tachycardic, with concern for hemorrhagic shock. She was awake and alert throughout. Arterial line was placed by Dr. DePinto, see separate note for details. Patient was transfused 1 unit pRBCs. She was started on vasopressor support. At this time, decision was made to transfer patient to ICU for post-operative care and additional resuscitation.
