cubbiecatz
Networker
We have a patient that had a c-section, and after completion of the surgery a large amount of blood was discovered. Large clots were evacuated but no mention of scraping performed. Then the Bakri was placed. My surgeon was the assistant for the c-section, but the operative note indicates she is the surgeon that placed the Bakri.
Can I bill for the unlisted code with her as the surgeon or I thought about adding modifier 22 the assistant surgeon charge for the delivery but that doesn't sound like something insurance would consider.
Here is the relevant portion of the Operative note:
The placenta was then removed with the use of fundal massage. The uterus cleared of all clots and debris. The uterine incision was repaired with 0 monocryl in a running, locked fashion. A second layer of the same suture was used to obtain excellent hemostasis. The gutters were irrigated and cleared of all clots. The fascia was reapproximated with 0 vicryl in a running fashion by both myself and Dr. B. The subcutaneous tissue was irrigated and made hemostatic with bipolar cautery and closed using 3-0 vicryl. The skin was closed with 4-0 monocryl.
After the completion of the surgery when the drape was removed the nurse noted a significant amount of blood on the under buttock drape as well as continued bleeding with fundal rub. The pad was weighed and amounted to 1700 cc. I was called back to the operating room and patient was noted to have continued vaginal bleeding. On exam her fundus was firm and the lower uterine segment appeared "floppy". Large clots were evacuated and the bleeding continued. She was administered 1 gram TXA, 600 mcg Cytotec as well as 0.2 mg IM Methergine. The massive transfusion protocol was instituted and 1 unit PRBC, FFP and Platelets were hung by anesthesia in the OR. Dr. B and myself were present and elected to reopen the incision to evaluate for active bleeding in the pelvis. The uterine incision was intact and no evidence of intraperitoneal bleeding. The fundus again was evaluated and noted to be firm. Dr. B performed a vaginal exam and the lower uterine segment was noted to be boggy. At this point she placed a Bakri using sterile technique and 300 cc saline. The fascia was closed again using 0 Vicryl with excellent hemostasis noted. The subcutaneous tissue was again irrigated using warmed normal saline and was re approximated with 3-0 Vicryl. The skin was closed using 4-0 Monocryl in a subcuticular fashion. Patient remained hemodynamically stable at the closure of the case. A second dose of Clindamycin was administered.
The patient tolerated the procedure well. Sponge, lap, needle and instrument counts were reported correct to the surgeon. The patient was taken to her recovery area in stable condition.
A qualified resident was not available.
Dr. B actively participated in assisting in this case with aiding in adequate retraction and exposure throughout the operation, delivery of infant, helping with proper visualization, suturing when needed, and extra monitoring for potential bleeding or other intraoperative complications.
Attending Attestation: I was present and scrubbed for the entire procedure.
Thank you,
Cathy Satkus, CPC, COBGC
Can I bill for the unlisted code with her as the surgeon or I thought about adding modifier 22 the assistant surgeon charge for the delivery but that doesn't sound like something insurance would consider.
Here is the relevant portion of the Operative note:
The placenta was then removed with the use of fundal massage. The uterus cleared of all clots and debris. The uterine incision was repaired with 0 monocryl in a running, locked fashion. A second layer of the same suture was used to obtain excellent hemostasis. The gutters were irrigated and cleared of all clots. The fascia was reapproximated with 0 vicryl in a running fashion by both myself and Dr. B. The subcutaneous tissue was irrigated and made hemostatic with bipolar cautery and closed using 3-0 vicryl. The skin was closed with 4-0 monocryl.
After the completion of the surgery when the drape was removed the nurse noted a significant amount of blood on the under buttock drape as well as continued bleeding with fundal rub. The pad was weighed and amounted to 1700 cc. I was called back to the operating room and patient was noted to have continued vaginal bleeding. On exam her fundus was firm and the lower uterine segment appeared "floppy". Large clots were evacuated and the bleeding continued. She was administered 1 gram TXA, 600 mcg Cytotec as well as 0.2 mg IM Methergine. The massive transfusion protocol was instituted and 1 unit PRBC, FFP and Platelets were hung by anesthesia in the OR. Dr. B and myself were present and elected to reopen the incision to evaluate for active bleeding in the pelvis. The uterine incision was intact and no evidence of intraperitoneal bleeding. The fundus again was evaluated and noted to be firm. Dr. B performed a vaginal exam and the lower uterine segment was noted to be boggy. At this point she placed a Bakri using sterile technique and 300 cc saline. The fascia was closed again using 0 Vicryl with excellent hemostasis noted. The subcutaneous tissue was again irrigated using warmed normal saline and was re approximated with 3-0 Vicryl. The skin was closed using 4-0 Monocryl in a subcuticular fashion. Patient remained hemodynamically stable at the closure of the case. A second dose of Clindamycin was administered.
The patient tolerated the procedure well. Sponge, lap, needle and instrument counts were reported correct to the surgeon. The patient was taken to her recovery area in stable condition.
A qualified resident was not available.
Dr. B actively participated in assisting in this case with aiding in adequate retraction and exposure throughout the operation, delivery of infant, helping with proper visualization, suturing when needed, and extra monitoring for potential bleeding or other intraoperative complications.
Attending Attestation: I was present and scrubbed for the entire procedure.
Thank you,
Cathy Satkus, CPC, COBGC