I'm just not sure how to code this postpartum office visit:
Subjective:
Patient here for incision check
Had repeat C-section (date) with incidental cystotomy
Bladder injury was repaired in 2 layers with intraoperative retrograde bladder fill with no leak
Patient has leg bag and will use for another week
Denies need for more pain meds
Is able to manage use of leg bag without too much difficulty
Objective: Incision - well healed, no erythema or induration
Problems addressed this Visit :
• Postnatal examination status (finding), Z39.2
s/p repeat C-section with bladder injury
Plan: Keep next appointment
Will keep using leg bag and taking Macrobid until next visit.
Would I use O34.21, maternal care for scar from previous cesarean delivery since the purpose of the visit is an incision check? Or just the Z39.2 for routine postpartum check?
And/or do I code the complication (cystotomy) since that is addressed? If so, what code? (Where do I start in the Index?)
I'm just lost with this one. Any help would be much appreciated!
Subjective:
Patient here for incision check
Had repeat C-section (date) with incidental cystotomy
Bladder injury was repaired in 2 layers with intraoperative retrograde bladder fill with no leak
Patient has leg bag and will use for another week
Denies need for more pain meds
Is able to manage use of leg bag without too much difficulty
Objective: Incision - well healed, no erythema or induration
Problems addressed this Visit :
• Postnatal examination status (finding), Z39.2
s/p repeat C-section with bladder injury
Plan: Keep next appointment
Will keep using leg bag and taking Macrobid until next visit.
Would I use O34.21, maternal care for scar from previous cesarean delivery since the purpose of the visit is an incision check? Or just the Z39.2 for routine postpartum check?
And/or do I code the complication (cystotomy) since that is addressed? If so, what code? (Where do I start in the Index?)
I'm just lost with this one. Any help would be much appreciated!