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Please help quick

  1. #1
    Default Please help quick
    Medical Coding Books
    I have a patient that came in for endometriosis and pelvic pain. She had a scheduled bilateral salpingo-oophorectomy and extremely extensive lysis of adhesions (per physican). During post-op, the patient went back to the OR for evacuation of a post-op hemoperitoneun and ligation of rectosigmoid mesentric bleeding. Without having both op notes to read, I was hoping that someone might be able to tell me if I am at least on the right track. Oh, and the patient was also being tranfused with blood during the second procedure as well. Will that be coded separately as well? I went with:


    Am I off track?

  2. #2
    Greeley, Colorado
    Hi Leslie - 58660 is inclusive to 58661 so it cannot be reported even with mod -59. If documentation supports the "extensive adhesions" I would use 58661-22. Your doc must document what was extensive about them and how much extra time it took to remove them.
    Lisa Bledsoe, CPC, CPMA

  3. #3
    Ok, thanks Lisa, and thanks for the quick reply. The documentation definitely supports the -22 so I'll add that. What about the other code? Was that right? And what about the transfusion that was given simultaneously, is it incidental to the procedure? I appreciate all of your help!!

  4. #4
    Greeley, Colorado
    Leslie - I'm not sure on the 3rd code, but it appears to be appropriate. Mod -78 would be the correct modifier. As far as the transfusion question - I don't think a physician can code for this since he/she is not performing it - it would be for the facility to code.
    Lisa Bledsoe, CPC, CPMA

  5. #5
    Ok, thanks again I actually am doing the facility fees on this as well, and I really do appreciate all of your help.

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