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Vaginal Tear

melinda1436

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If a CNM who does home births has to repair a tear, is it coded using the 12001 - 13132 range of codes? Or would it fall under the epesiotomy area of 59400?
 
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Unless the tear is 3rd or 4th degree , it would be considered part of the global 59400. If it is a 3rd or 4th degree , there is not a specific code for the repair, but you can submit 59400-22 to indicate the extra work. You will need to explain why you have added the 22 modifier. Some plans will pay additional, but my experience has been that most do not.
 
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Here is an article on 3rd and 4th degree repairs form the OB/GYN Pink Sheets. I have used both the -22 and the repair codes and have better luck with the repair codes. You can include this article with your claim.


Subject Don't bill for repair of first, second-degree lacerations after delivery
Source Coder Pink Sheets: Ob/Gyn
Publication Ob/Gyn: ObGyn Coder's Pink Sheet, October 2008, Vol. 7, No. 10
Effective Date Oct 3, 2008
Publish Date Oct 3, 2008

When the ObGyn delivering the baby performs an episiotomy, the procedure is included (whether delivery only or global OB package) and you can't report it separately, according to CPT guidelines. But sometimes, especially in women having their first vaginal birth, a laceration, or tear, of the perineum may occur during a delivery (whether or not an episiotomy was performed).
In such cases, if and how you can bill depends on the following two factors:
• The extent of the laceration.
• Whether the repair was performed by the same physician who delivered the baby.
Laceration types: From a clinical standpoint, lacerations are classified by degree. The most superficial tears involve the skin of the perineum, the tissue around the opening of the vagina or the outermost layer of the vagina itself. These first-degree lacerations typically heal quickly.
Second degree lacerations, on the other hand, may take weeks to heal, as they extend into the muscle below the skin and require layered closure (intermediate or complex repairs).
Third- and fourth-degree lacerations are more severe, and may occur in one out of every 25 vaginal deliveries. A third-degree laceration involves a tear in the vaginal tissue, perineal skin and perineal muscles that extend into the anal sphincter. A fourth-degree laceration cuts through the anal sphincter and the tissue beneath it.
A woman is more likely to suffer third- and fourth-degree lacerations during a vaginal delivery if:
• she has previously given birth vaginally and had a third- or fourth-degree laceration;
• she has an assisted delivery;
• forceps are used;
• the baby is large;
• the baby is born face-up; and
• the distance between the vaginal opening and anus is shorter than normal.
When you can bill: According to the American College of Obstetricians and Gynecologists (ACOG), "the repair of first- and second-degree lacerations are not to be reported separately." However, ACOG notes that third and fourth degree lacerations require "significant additional physician work" because they extend beyond the perineum "into areas such as the rectum and anus," and as a result, you should obtain additional payment for them.
What you can bill - Option 1: ACOG's Coding Committee suggests two options for reporting third and fourth degree laceration repairs. The first is to append modifier 22 (increased procedural service) to the appropriate delivery or global package code. As with all claims involving modifier 22, you'll need to provide documentation that describes the extent of the injury and the amount of additional time the ObGyn spent performing the repair. It's also a good idea to send along a KISS (keep it short and simple) note describing what the ObGyn did, why he/she did it, and the percentage of additional work compared to a normal delivery. Also be sure to increase the fee, as the payer is unlikely to do so for you.
Consider Option 2: Many practices may prefer ACOG's second option, which is to bill the appropriate integumentary repair code. If an intermediate (layer) closure was performed, use the appropriate code from the 12041-12047 series of codes. If a more complex repair was done, use 13131-13133 as appropriate.
When another physician performs the delivery and the ObGyn is called in specifically to repair the laceration, none of the above applies. For example, if the woman's primary care physician delivers the baby but cannot repair the tear (regardless of degree), then the ObGyn called in to perform the repair would bill 59300 (episiotomy or vaginal repair, by other than attending physician). As indicated in the code description, the ObGyn also may bill this code for the repair of an episiotomy. The code pays about $140 (facility fee, unadjusted for location).
Official resource:
To view ACOG guidelines on laceration repairs following delivery, go to: www.acog.org/departments/dept_notice.cfm?recno=6&bulletin=4645
Other types of lacerations
During a delivery, lacerations in areas other than the perineum also may occur. A periurethral laceration, for example, involves a tear at the top of the vagina near the urethra. A sulsus laceration is a deep tear into the vaginal tissue. Lacerations of the cervix and labia also may occur, though these are much less common.
The information contained herein was current as of the publication date. © Copyright DecisionHealth, all rights reserved. Electronic or print redistribution without prior written permission of DecisionHealth is strictly prohibited by federal copyright law.
 
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