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Michelle Posted Wed 07th of February, 2018 09:21:09 AM
I am unsure how to charge for this. What would the cpt code and diagnosis code be for this? Delivery was done by one of our doctors in the practice and the vaginal packing was done by another doctor in our practice the following day. Thank you
SuperCoder Answered Fri 09th of February, 2018 02:17:58 AM

Control of bleeding during an operative procedure is an integral component of a surgical procedure and is not separately reportable. Postoperative control of bleeding not requiring return to the operating room is included in the global surgical package and is not separately reportable. However, control of bleeding requiring return to the operating room in the postoperative period is separately reportable utilizing modifier 78.

You should use the unlisted procedure 58999. Append 78 modifier to the CPT code for unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period).

NOTE: When submitting an unlisted-procedure code, your documentation should also include an explanatory cover letter. An insurer will decide to pay an unlisted-procedure claim by comparing your procedure description to a similar, listed procedure with an established reimbursement value.

Insurer will compare the work to 57023 (Incision and drainage of vaginal hematoma; non-obstetrical [e.g., post-trauma, spontaneous bleeding]).

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