Maybe not frequently, but it happens often enough — a chart comes across your desk that leaves you scratching your head. What ob-gyn medical coder doesn’t get stumped once in a while?
If you have ob-gyn coding questions and worry about the time it takes to find answers, you’ve come to the right place. In today’s post, we’ve asked Suzanne Burmeister, managing editor of TCI’s Ob-Gyn Coding Alert, and ob-gyn coding expert, Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, NM, to apply their expertise to a few reporting conundrums presented by ob-gyn coders like you.
One hour after a vaginal delivery, the patient was having a postpartum hemorrhage. She was brought back to the OR where she underwent an exam under anesthesia (EUA), repair of posterior uterine wall laceration, and vaginal packing. The laceration was of the intravaginal portion of posterior uterine wall and was 3 cm in length.
The physician was later notified that bleeding continued past the vaginal packing. He took the patient back into OR where she underwent EUA. A laceration of the right lateral cervical wall with minimal bleeding was repaired with 2-0 Vicryl continuous locking suture. The physician then noted continued bleeding coming from a posterior location where further examination revealed a laceration of the posterior cervical wall mucosa approximately 3 cm in length that extended to the posterior fornix. The lateral fornices were intact, and the laceration was repaired with 2-0 Vicryl continuous suture.
What CPT® codes should I use for the repair of the cervical lacerations, and do I code them separately?
Solution: The EUA and the vaginal packing are bundled if you bill for a repair. The closest code would be 59350 (Hysterorrhaphy of ruptured uterus) for the laceration of the uterus. Keep in mind, however, the uterus was not ruptured, and this code has a fairly high relative value unit (RVU of 7.98).
For the return to OR, try using the code for trachelorrhaphy (57720, Trachelorrhaphy, plastic repair of uterine cervix, vaginal approach). It appears that both the remaining issues involved the cervix.
What is the correct way to code for type 2 diabetes and a urinary tract infection (UTI)? Should I use E11.69 or E11.29?
Solution: The correct way to code for this depends on how your provider documented the patient’s condition. Is the patient’s diabetes the cause of the UTI? This is often the case for patients whose diabetes is long-term and poorly controlled and who have developed complications such as renal papillary necrosis, cystopathy, or nephropathy. In these situations, E11.69 (Type 2 diabetes mellitus with other specified complication) or E11.29 (Type 2 diabetes mellitus with other diabetic kidney complication) may be appropriate codes to use.
Should you go with E11.69, however, you should be aware of the “Use additional code to identify complication” note that goes with it. This means you would code the UTI, as well using a code such as N39.0 (Urinary tract infection, site not specified), N10 (Acute pyelonephritis), N30.- (Cystitis), N34.- (Urethritis and urethral syndrome), or O23.4- (Unspecified infection of urinary tract in pregnancy) as appropriate.
However, should the provider document that the two conditions are unrelated, you’ll code the diabetes with E11.9 (Type 2 diabetes mellitus without complications) and an appropriate code for the UTI, assuming that the ob-gyn addressed both conditions during the encounter.
I’m attempting to understand the issue of laparoscopic pelvic lymphadenectomies done in conjunction with other laparoscopic surgery. In the CPT® book, there are two codes for laparoscopic pelvic lymphadenectomies: 38571 and 38572. I’ve been unable to find a list of lymph nodes (or groups of lymph nodes) that constitute a laparoscopic “bilateral total pelvic lymphadenectomy.” I have several questions since I haven’t been able to find this information:
Solution: First, check out the descriptors for the two procedure codes you mentioned:
The external iliac, internal iliac, and obturator (hypogastric) nodes are all part of a pelvic lymphadenectomy. And while the code’s description doesn’t indicate which nodes are to be removed, the clinical vignette used to add this code to CPT® does.
According to the description of the procedure, “The peritoneum is incised overlying the external iliac vessels, and lymph node dissection is performed. Boundaries of the dissection are the genitofemoral nerve laterally, the circumflex iliac vein or Cloquet’s node inferiorly, the bladder medially, the bifurcation of the common iliac artery superiorly, and the floor of the obturator fossa deep. All lymph-node-bearing tissue in this area is removed to include external iliac, internal iliac, and obturator (hypogastric) lymph node.”
While the number of nodes removed isn’t specified, the intention is that all nodes within the area are to be removed bilaterally to use these codes.
Caveat: Remember if the surgeon performs only a unilateral resection, append modifier 52 (Reduced services) to 38571 and document the ob-gyn’s work.
If the ob-gyn removes nodes located higher than the pelvic nodes (e.g., those at and above the aortic and vena cava bifurcation), submit 38572 for an extended node resection.
Finally, clinically there is no discrete delineation between the groups of nodes because of the many anatomical lymph node variations. It would be appropriate to use the unlisted code for a limited laparoscopic lymphadenectomy.
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The Coders’ Specialty Guide 2019: Obstetrics & Gynecology includes all CPT® and HCPCS codes relevant to ob-gyn, simple descriptions that explain each code, expert advice for assigning codes, Medicare reimbursement details, diagnosis codes crosswalk, applicable modifiers, CCI edits, global days, code index, hundreds of anatomical illustrations, and more.