Wiki Patient delivers then two days later they find a 2nd degree tear which they went in and repaired. CPT code would be?

[allowry5]

I reached out to my team and we have three codes. 59400, 59300, and 12041


OP NOTE:


Date of Procedure:　1/18/2021


Pre-op Diagnosis:　rectal mucosal tear after vag del 2d ago


Post-op Diagnosis:　same as above


Procedure Performed:　take down of original 2nd degree repair, copious irrigation, repair of rectal mucosa, repair of 2nd degree laceration.





Anesthesia:　iv sedation, with ~ 40ml 1% lidocaine local infiltration

Estimated Blood Loss　30ml

Drains:　none


Specimen:　No


Wound Class:　Dirty or Infected: 　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　Open, fresh, accidental wounds. 　In addition, operations with major breaks in sterile technique, (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, non-purulent inflammation is encountered including necrotic tissue without evidence of purulent drainage (e.g., dry gangrene) are included in this category. 　No purulence/infection observed.


Incision Closure:　Deep and Superficial Layers


Complications:　No


Condition of Patient:　good


​

HISTORY/INDICATIONS

S/p vaginal delivery 48hours ago, returned to office complaining of stool coming out of vagina. 　Rectal exam in office showed laceration of rectal mucosa. 　At delivery this was not noted.





DESCRIPTION OF PROCEDURE:


Patient was taken to the operating room where iv sedation was placed. 　She was placed in dorsal lithotomy position. 　She was prepped and draped in usual sterile technique. 　Prior 2nd degree episiotomy repair was taken down. 　Sphincter exam was wnl. 　It was not involved. 　Copious irrigation performed. 　4-0 vicryl was used to reapproximate the rectal mucosa. 　It was anchored cephalad and then in a running manner brought the two sides in proximity. 　Copious irrigation performed 3x during the closing. 　At the distal aspect the mucosa was intact. 　The laceration did not extend all the way to the anus, through the sphincter. 　The tissue between the vaginal mucosa and rectal mucosa was then reaproximated with figure of 8s of 3-0 vicryl. 　An additional 3-0 vicryl was used in a running manner to reaproximate the vaginal mucosa. 　Gloves were changed 4x during the procedure for rectal checks and increase cleanliness. 　Sponge, lap and instruments counts were correct. 　Patient was taken to recovery room and d/c home in excellent condition.​

She is encouraged to keep soft stool and take augmentin 875mg bid for 1wk.

 

[nielynco]

I reached out to my team and we have three codes. 59400, 59300, and 12041


OP NOTE:


Date of Procedure:　1/18/2021


Pre-op Diagnosis:　rectal mucosal tear after vag del 2d ago


Post-op Diagnosis:　same as above


Procedure Performed:　take down of original 2nd degree repair, copious irrigation, repair of rectal mucosa, repair of 2nd degree laceration.





Anesthesia:　iv sedation, with ~ 40ml 1% lidocaine local infiltration

Estimated Blood Loss　30ml



Drains:　none





Specimen:　No





Wound Class:　Dirty or Infected: 　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　Open, fresh, accidental wounds. 　In addition, operations with major breaks in sterile technique, (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, non-purulent inflammation is encountered including necrotic tissue without evidence of purulent drainage (e.g., dry gangrene) are included in this category. 　No purulence/infection observed.





Incision Closure:　Deep and Superficial Layers





Complications:　No





Condition of Patient:　good








HISTORY/INDICATIONS



S/p vaginal delivery 48hours ago, returned to office complaining of stool coming out of vagina. 　Rectal exam in office showed laceration of rectal mucosa. 　At delivery this was not noted.











DESCRIPTION OF PROCEDURE:





Patient was taken to the operating room where iv sedation was placed. 　She was placed in dorsal lithotomy position. 　She was prepped and draped in usual sterile technique. 　Prior 2nd degree episiotomy repair was taken down. 　Sphincter exam was wnl. 　It was not involved. 　Copious irrigation performed. 　4-0 vicryl was used to reapproximate the rectal mucosa. 　It was anchored cephalad and then in a running manner brought the two sides in proximity. 　Copious irrigation performed 3x during the closing. 　At the distal aspect the mucosa was intact. 　The laceration did not extend all the way to the anus, through the sphincter. 　The tissue between the vaginal mucosa and rectal mucosa was then reaproximated with figure of 8s of 3-0 vicryl. 　An additional 3-0 vicryl was used in a running manner to reaproximate the vaginal mucosa. 　Gloves were changed 4x during the procedure for rectal checks and increase cleanliness. 　Sponge, lap and instruments counts were correct. 　Patient was taken to recovery room and d/c home in excellent condition.​

She is encouraged to keep soft stool and take augmentin 875mg bid for 1wk.

As you are billing for the global delivery which includes the initial episiotomy, you cannot bill 59300 as this code is for the non-delivering physician only (but non-delivering refers to a provider not affiliated with your practice, not a provider in your practice who did not do the delivery). To bill 59300 it would have to be performed by someone not affiliated with your practice. By saying one of your choices is 59400, I will assume this provider is in your practice and 59300 is not an option. If that is true and given there is no wound size documented the code 12041 is your best bet with a modifier -78 added.