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Wiki help!-My doctor is a

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mamacase1

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My doctor is a family practice doctor that had a patient come in post 2 days delivery. Dictation says pt is here for check status post delivery. She did have a vaginal delivery 2 days ago and felt like stitches tore here recently. Exam : There is no active bleeding. On the posterior fornix there is a samll are that is open a little bit but tissues are staying cloased and I do not see this is an open wound.

DX: Recheck status post delivery with torn episiotomy

At this point in time no fruther treatment will recheck in about a week to see houw this is doing.

I would of thought that she would have followed up with her OB/GYN but since she didnt how would you colde this. ICD9?:confused:
 
mamacase1 said:
my doctor is a family practice doctor that had a patient come in post 2 days delivery. Dictation says pt is here for check status post delivery. She did have a vaginal delivery 2 days ago and felt like stitches tore here recently. Exam : There is no active bleeding. On the posterior fornix there is a samll are that is open a little bit but tissues are staying cloased and i do not see this is an open wound.

Dx: Recheck status post delivery with torn episiotomy

at this point in time no fruther treatment will recheck in about a week to see houw this is doing.

I would of thought that she would have followed up with her ob/gyn but since she didnt how would you colde this. Icd9?:confused:
Click to expand...

cpt 59430, 665.5, V24.2 (I think) ;)
 
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I would not use the CPT 59430. This would be a low level E/M. For the ICD-9, I would go with the 665.54. I don't care for the V24.2, this was not really a routine postpartum follow up.

Lisa Hair, CPC, CPMA
 
I agree with 674.24 with an E&M w/ modifier 24 (because it is in the global delivery time frame)
Postpartum 59430 is coded for the standard postpartum at the estimated 6 wks after delivery.
 
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