Question uterine extension

rleif1sun

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Monroe, NY
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Hi I need some help here in regards to c/section with uterine extension
is there anything I can bill in addition to the primary c-section code 59510 or is it bundled? see below


The uterus was closed. There was a small extension in the uterus. An initial attempt was to close the uterus with
the extension, but there was still a defect and the extension was closed separately. There was a fair amount of bleeding including the extension down into the lower
segment, but at the end, it was dry and there was a double layer closure. The uterus was not exteriorized. Previous to closing the uterine incision, it had been wiped
free of residual debris with moist lap. Following closure of the uterus and evacuation of fluid from the gutters, inspection of the tubes and ovaries which were
normal, the peritoneum was left open. The rectus muscle was reapproximated in the midline. The fascia was closed with a running locked 2-0 Prolene suture. The
subcutaneous tissue was irrigated. 2-0 plain suture was used to close subcutaneous tissue after several subcutaneous bleeders were coagulated. It was dry. Surgical
staples were applied. Sponge, instrument, needle count was correct x2. The Foley was draining crystal clear urine at the end of the procedure.
 

nielynco

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Guadalupita, NM
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Hi I need some help here in regards to c/section with uterine extension
is there anything I can bill in addition to the primary c-section code 59510 or is it bundled? see below


The uterus was closed. There was a small extension in the uterus. An initial attempt was to close the uterus with
the extension, but there was still a defect and the extension was closed separately. There was a fair amount of bleeding including the extension down into the lower
segment, but at the end, it was dry and there was a double layer closure. The uterus was not exteriorized. Previous to closing the uterine incision, it had been wiped
free of residual debris with moist lap. Following closure of the uterus and evacuation of fluid from the gutters, inspection of the tubes and ovaries which were
normal, the peritoneum was left open. The rectus muscle was reapproximated in the midline. The fascia was closed with a running locked 2-0 Prolene suture. The
subcutaneous tissue was irrigated. 2-0 plain suture was used to close subcutaneous tissue after several subcutaneous bleeders were coagulated. It was dry. Surgical
staples were applied. Sponge, instrument, needle count was correct x2. The Foley was draining crystal clear urine at the end of the procedure.
This does not describe significant additional work so I think this documentation would not support use of a modifier -22. It certainly does not describe a rupture of the uterus that needed to be repaired. I would consider it included.
 
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