Korbc
Guru
hello,
I was looking for help with coding this case if anyone would know what would be the equivalent of the OB versions of codes 56810 and 59300. I don't know if I should just code 13131 for this case. Here's the description below... also the attending physician who delivered the baby did this surgery herself in the OR following delivery.
Excessive postpartum bleeding.
POSTOPERATIVE DIAGNOSIS:
Excessive postpartum bleeding with a vaginal hematoma.
PROCEDURE:
Vaginal repair of a hematoma.
SURGEON:
Kellen Sikora, MD
FINDINGS:
Perirectal hematoma on the perineum with persistent bleeding.
ANESTHESIA:
Epidural and sedation.
ESTIMATED BLOOD LOSS:
150 mL in the OR and another 650 in the room.
SPECIMENS:
None.
PROPHYLAXIS:
The patient received Ancef prior to her procedure.
DESCRIPTION OF PROCEDURE:
After the patient had a vaginal birth with spontaneous placenta delivery, excessive brisk bleeding was noted. Attempted to repair the perineal laceration in the room with suction and retraction and after an epidural bolus, but unable to visualize appropriately. At that point, she was consented. She was taken to the operating room where her anesthesia was found to be adequate, was able to visualize repair better. The site of the repair distally to the previous sutures was oozy, sutures were placed, more oozing was noted and seeping from deep, multiple sutures were placed, locking and interrupted to try to stem the bleeding. This greatly improved the bleeding, but there was still a slight ooze and so vaginal packing was placed. Foley catheter was placed. At that point, the patient was taken to the recovery room in good condition. Counts were correct x2.
I was looking for help with coding this case if anyone would know what would be the equivalent of the OB versions of codes 56810 and 59300. I don't know if I should just code 13131 for this case. Here's the description below... also the attending physician who delivered the baby did this surgery herself in the OR following delivery.
Excessive postpartum bleeding.
POSTOPERATIVE DIAGNOSIS:
Excessive postpartum bleeding with a vaginal hematoma.
PROCEDURE:
Vaginal repair of a hematoma.
SURGEON:
Kellen Sikora, MD
FINDINGS:
Perirectal hematoma on the perineum with persistent bleeding.
ANESTHESIA:
Epidural and sedation.
ESTIMATED BLOOD LOSS:
150 mL in the OR and another 650 in the room.
SPECIMENS:
None.
PROPHYLAXIS:
The patient received Ancef prior to her procedure.
DESCRIPTION OF PROCEDURE:
After the patient had a vaginal birth with spontaneous placenta delivery, excessive brisk bleeding was noted. Attempted to repair the perineal laceration in the room with suction and retraction and after an epidural bolus, but unable to visualize appropriately. At that point, she was consented. She was taken to the operating room where her anesthesia was found to be adequate, was able to visualize repair better. The site of the repair distally to the previous sutures was oozy, sutures were placed, more oozing was noted and seeping from deep, multiple sutures were placed, locking and interrupted to try to stem the bleeding. This greatly improved the bleeding, but there was still a slight ooze and so vaginal packing was placed. Foley catheter was placed. At that point, the patient was taken to the recovery room in good condition. Counts were correct x2.
