Coding Suggestion Needed


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Good Afternoon,

I am hoping someone can help me out with what they believe we can code for this MD's participation in the patient's C-section. There was already a primary surgeon and assistant surgeon present. Below is the note from my provider:

Called to OR for emergent consultation on a 27 year-old G5 P3 at 40+ weeks gestation who underwent an emergent primary low transverse cesarean delivery for nonreassuring fetal heart rate tracings at approximately 5 cm dilation.

She had rupture of membranes for less than 24 hours/clear fluid. Upon entering the abdomen, it was noted that the uterus was ruptured in a stellate fashion in the contractile part of the anterior aspect of the uterus. The infants right arm was outside of the uterus. No prior uterine incisions or surgeries.

By report Dr. X extended the horizontal aspect of the rupture to a size and allowed her to complete the delivery. The infant was in cephalic presentiation. It was a viable infant.

The placenta was delivered manually, the incisions and tears were closed primarily by Dr. X with 0 vicryl suture.

I was called for consultation secondary to hemorrhaging from the uterine incisions and tears. By report by the time I had entered the OR her estimated EBL was between 1500 and 2000 cc.

I inspected the abdomen, and hemostasis was much improved. I placed several interrupted and running 0 Vicryl sutures to get good control of hemostasis.

At this time I performed pelvic exploration with the following findings:
There is no extension of the uterine tears. Tears are localized to the anterior aspect of the uterus. No involvement of uterine vasculature. Tears did not extend down to the area of the bladder. Bowels were unremarkable.

Once inspection was complete the fascia was closed with 0 PDS suture in a running fashion. Suprafascial irrigation was performed, the dead space was closed with 3-0 Vicryl interrupted sutures, and the skin was closed with staples. Sterile dressings were applied.

At the conclusion of this procedure the uterus was firm and located at the U-2 position.