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help!-My doctor is a

  1. Question help!-My doctor is a
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    My doctor is a family practice doctor that had a patient come in post 2 days delivery. Dictation says pt is here for check status post delivery. She did have a vaginal delivery 2 days ago and felt like stitches tore here recently. Exam : There is no active bleeding. On the posterior fornix there is a samll are that is open a little bit but tissues are staying cloased and I do not see this is an open wound.

    DX: Recheck status post delivery with torn episiotomy

    At this point in time no fruther treatment will recheck in about a week to see houw this is doing.

    I would of thought that she would have followed up with her OB/GYN but since she didnt how would you colde this. ICD9?

  2. #2
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    Quote Originally Posted by mamacase1 View Post
    my doctor is a family practice doctor that had a patient come in post 2 days delivery. Dictation says pt is here for check status post delivery. She did have a vaginal delivery 2 days ago and felt like stitches tore here recently. Exam : There is no active bleeding. On the posterior fornix there is a samll are that is open a little bit but tissues are staying cloased and i do not see this is an open wound.

    Dx: Recheck status post delivery with torn episiotomy

    at this point in time no fruther treatment will recheck in about a week to see houw this is doing.

    I would of thought that she would have followed up with her ob/gyn but since she didnt how would you colde this. Icd9?
    cpt 59430, 665.5, V24.2 (I think)
    Last edited by btadlock1; 03-14-2011 at 09:46 PM.

  3. Default
    Thank you for your help Brandi

  4. Default
    I would not use the CPT 59430. This would be a low level E/M. For the ICD-9, I would go with the 665.54. I don't care for the V24.2, this was not really a routine postpartum follow up.

    Lisa Hair, CPC, CPMA

  5. #5
    Location
    Fayetteville, NC
    Posts
    300
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    What about 674.24 (other specified complications of the puerperium, NEC; disruption of perineal wound; disruption of wound episiotomy; postpartum condition or complication) as a diagnosis code?
    A. McCormick, CPC, CGSC
    Walters Surgical Associates

  6. #6
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    Quote Originally Posted by Grintwig View Post
    What about 674.24 (other specified complications of the puerperium, NEC; disruption of perineal wound; disruption of wound episiotomy; postpartum condition or complication) as a diagnosis code?
    I like that one better than either of mine...

  7. #7
    Location
    Fayetteville, NC
    Posts
    300
    Default
    My intern found it
    A. McCormick, CPC, CGSC
    Walters Surgical Associates

  8. #8
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    I agree with 674.24 with an E&M w/ modifier 24 (because it is in the global delivery time frame)
    Postpartum 59430 is coded for the standard postpartum at the estimated 6 wks after delivery.
    The Oracle

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