If I may please have assistance from the experts. A patient was scheduled for a repeat c-section. This is part of the op report: We began the procedure with a pfannestiel type incision through her previous scar. We disected down through the subcutaneous tissue until the anterior of the fascia was noted.. .I then created a low-transverse incison of the lower uternine segment and immediately noted that we were passing through the placenta for the delievery of this baby. The incision was carried laterally with blunt traction and I ruptured the bag of water after dissecting through the placenta. The increased blood loss for the procedure was mostly because of the anterior placenta. Thre was no uterine atony noted. Clear fluid was noted. Attempts to deliever the fetal vertex trhough the opening were difficult secondary to the placenta protruding through the incision as well. Despite manipulation of the vertex as well as the fundal pressure the head could not be delievered and therefore I elected to use the vacuum in order to deliever the fetal vertex."
I will bill the following:
Previous c-section (ICD 9 654.21)
Anterior Placenta (ICD 9 656.71)
Vacuum Extraction ( ICD 9 669.51)
Repeat low transverse cesarean section with vacuum assisted delivery - CPT 59510
Thank you for your help.
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