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campy1961

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I am new to coding OB-GYN and having difficult with a procedure.

Pt had a LEEP (57460) earlier in the day and went back with vaginal bleeding and what the physician did was cauterized the LEEP site.

Here is part of the OP note:

There was bledding at 2 o'clock and 7 o'clock along with general oozing from the bed of the LEEP procedure. At that time, ball cautery was used to provide hemostatsis. Monsel solution was placed on a long Q-tip and held pressure on the LEEP site.

I am not really sure what to use???

Thanks for your help in advance.
Connie - CPC
 
Minor surgery categories are either 0 or 10 days global period.(medicare).
This LEEP has a 0-Day global period and all pre-op and post op visits should be billed using office E/M Codes(99201-99215).
For procedures with a global period of 10days, pre-op care still be charged using E/M codes. However you should not bill for Post Op services, related to normal recovery from the surgery during the 10_day post-op period.
Treatment of complications is always a billable service, using the standard office visit E/M codes, linked to a diagnosis describing the complication.

E/M visit codes may be charged the same day of a minor surgery or during the global post op period, IF A SIGNIFICANT, SEPARATELY IDENTIFIABLE SERVICE IS FURNISHED, Use a modifier -24 or 25, and document diagnosis carefully.
Again, it is best to use a different diagnosis to clarify that the E/M service was UNREALTED TO THE PROCEUDRE.
Hope this give you aclue
 
That is great information but this was done in the OR. Patient was in recovery had complications and went back to the OR the same day.

Thanks
 
You would append modifier - 78 to the original procedure and electro cautery of the cervix 57510- 59.
Ball cautery is only an electrocoagulation procedure.
 
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