OBYGYN Medical Coding and Case Studies Transcript
Hello, everyone! We’re gonna have fun tonight. It’s another Live with CCO. We’re at episode number 92 and we’re gonna have fun because we’re gonna do some case studies. I really love our case studies. We don’t do them live like this as often as maybe we could but because of that one of the reasons that we wanted to show you how we work with case studies is because the new course that we’re launching has, it’s almost, you know, 98% all case studies and it’s an advanced coding course. We’ll tell you more about it at the end. However, there were some questions that came in about coding for obstetrics or OBGYN. So, I picked two case studies and we’re gonna walk through them and I’m going to show you how to abstract, how to look for the code within the case, and know that this is the type of study that we do with our new advanced course.
So, if this resonates with you and you want to get involved with how we educate for a more advanced abstracting picking the codes to the highest specificity and talking about the disease process along the way that might be something you’ll be interested in. And hey, we’re on TikTok now. We just joined TikTok. I am not a person that was on TikTok very much but we were going to give it a try if you’re on TikTok. The link is there and you can go in and like what we put up so far and look for more things in the future. We are mostly heavy in social media on our YouTube because you know, we’ve been in there for a decade but we’re also on LinkedIn and Facebook, now TikTok and Instagram, and some of those others. So keep an eye out for us.
OBYGYN Medical Coding and Case Studies
OBGYN medical coding cases and studies. That’s what we’ve picked tonight because we’ve had some questions about that. We are going to keep this up in YouTube. So, if you want to go back and reference later know that it’ll still be there. Feel free to share with your friends too and your peers or your colleagues or if you know somebody that struggles with this particular area, maybe what we go over tonight is just a little tidbits and highlights will be beneficial to them. We always like for other people to find out about us via word of mouth.
I have two case studies. We’re going to do a female cyst. We’re also going to do a cesarean delivery in the first case study. Let me go ahead and downsize this so we can get right in it. Hopefully, you’ll be able to see this. All right. Oops. There we go. I thought why isn’t coming up? This is an inpatient chart and we’re not doing any PCS. These will be CPT codes. However, know that this is the type of documentation you’re going to see. When I first start looking at the documentation, I want to make sure all the information is correct. Now, of course, this is redacted made-up names because this is a case study in the textbook that we use and so many of the names are fictional.
Now, let’s see here this particular patient. We would want to verify the name before we start plugging in codes and that everything’s accurate. We have an attending physician Dr. Green and a surgeon Dr. Martinez. The next thing that you’re going to look at is the pre and post-off diagnosis or diagnoses, depending on how many there are. This is a large left ovarian cyst. What are they going to do? Probably they’re going to get rid of this cyst. The next thing that we do if you’re depending on what your role is say, if you’re doing risk adjustment, you’ll start looking at signatures and make sure this is a valid encounter that you can code off of for in-house.
Again, there are different rules for different people. So depending on at what stage you’ll be pulling the codes, they may have you preemptively pulling the codes before it’s signed off on and then double-checking and nodding it after that. Again, everybody has different workflows and procedures. So, really the first thing that I want to do is see if the pre-op in the post-off match and it does. If not, don’t assume that the pre-op in the post office is going to match. If they have gotten in there and they looked at the cyst and they found endometriosis like they thought well, we’re only going to see the cyst and that’s what our focus is, but they get in there and they say, oh my there’s endometriosis here. Then the post-stop could have additional diagnoses or the diagnosis could be changed. Maybe this isn’t an ovarian cyst like they thought. They got in and got a better view and it was actually a neoplasm or something. Usually, they know ahead of time because the imaging is so good. But again, those are things to be aware of.
The pre-op and post-op need to be noted to see if there’s any change then the procedure. What’s the procedure that’s being done? A laparoscopic drainage of the left para tubal cyst. Now, think about this they’re going on in to take care of cyst. They are draining the cyst. Are they removing the cyst or draining the cyst? The procedure that was performed, that’s past tense, is saying that they only drained the cyst. A lot of times they take them out. That makes a difference in the codes that you’re picking. Okay?
We’re going to go ahead and I’m going to just highlight things that I think are pertinent along the way. Let’s pick a pretty color since we’re doing highlight. My favorite color is green. So, we’re gonna pick that. How old the patient is? Does not matter unless you’re doing procedures where the patient is of extreme age. Sometimes codes will change for extreme age. And this is not one of those procedures but be very mindful of that. They will always say whether it’s male-female and the age of the patient. Then it’ll go straight into the introduction of what the plan is for. Note, this is not necessarily definitive information. This is a summation of hey, this is what’s going on and why we’re doing this procedure. That’s usually the first thing that you read then you get into the procedure.
So, we have a 27-year-old female that has a large left ovarian cyst and they located it via ultrasound. The cyst was measuring up to eight centimeters and there was thought to be at least one sepitation within that. The patient was having increasing problems with their regular menses along with increasing left lower quadrant pain. The decision was therefore made to proceed with a laparoscopic procedure with the aim of draining the ovarian cyst. The idea is to drain the cyst. Now, why they’re not going to remove it? Maybe there’s a reason. It’s not for us to know except to keep a close eye on whether it changes and they eventually take out the cyst, right? Okay.
Moving on. Now, let’s get into the meat of it. What’s the procedure that’s being done? We know here that they are draining the ovarian cyst. So, I’m going to highlight that. I think I got to do it every time. That’s the procedure. The first section of your procedure reports is always going to be the setup, you know. They have to for legal purposes and just documentation standard practice. Is there going to stay exactly what’s done to the patient? How they were prepped? How it was set up and then getting into the procedure? So, that’s what we’re seeing here patients take into the operating room and general anesthesia is administered.
Now, there will be a separate anesthesia report via the anesthesiologist. They have a separate report. Okay, and the patient was then prepped and draped and they talk about the way the patient was positioned. The bladder was drained. Sometimes when they’re doing ultrasounds and things like that, they want the bladder expanded. When they’re going and doing the procedure, a lot of times they want to make sure that there’s nothing in the bladder. So, instead of having the patient get up and down and stuff, they’ll just go ahead and make sure it’s done with a straight cath. Okay? So, what they did is they went ahead and put in a speculum to help visualization of the cervix and then this is done laparoscopically. They used a single-tooth tenaculum, and that is a clamp that has teeth on it so we can grab it. And then, this is all fodder. We don’t care when you’re coding. This is information that we don’t need.
Now, I’m not saying don’t pay attention to some of these words in this verbiage, but for the most part, we don’t care how something was grasped unless there’s a complication or stuff. Whichever tool that they use to do the procedure, very seldom is part of our coding process. Now, I’m not saying that it’s not. We want to know if it’s open laparoscopic and so on and so forth and that verbiage will tell us a lot but, you know, if you’ve got one provider who uses a single tooth tenaculum and another one use something else, that really doesn’t matter to us. So, know that it’s okay when you’re going through this process to skim over that information. I call it fodder.
Again, Cohen cannula, we don’t care but so they were wanting to manipulate the uterus. They want to get the uterus out of the way. All this stuff’s packed in there pretty tight. Let’s see at this point. The gloves were changed and attention was directed towards the abdomen. The umbilical incision whenever they do laparoscopic they’re gonna stick a hole in your belly button. It was made to allow the insertion of the Veress needle and then this was done without incident. Again, the next thing they do once they put a hole in your belly button so they can get around in there and start putting in these additional ports is they inflate the abdomen with carbon dioxide. They use three liters. Now, that doesn’t go away. You have to actually suck that out. If they don’t get all of it sucked out then you’ll have pain up in your chest like in your collarbone and stuff. So, really nice surgeons will try to do a very very good job of getting all that out of your body. Otherwise, your body just absorbs it. Then we got a trocar was placed through the umbilical incision without incident.
Why do you think it keeps saying without incident, without incident, without incident? Because if this is a legal document and if there were ever any complications or anybody came back and said, well, it was a problem and my belly button, you know, herniated duh-duh-duh-duh after this procedure. Well, it was stated here there was no incident, you know, everything was fine. So it wasn’t because of that. Okay, at this point they inspect the pelvis. They’re in there looking around now. Immediately apparent was the large simple appearing cyst occupying the majority of the palace. Again, eight centimeters is big. In fact, it was impossible to get around the cyst to be able to inspect or identify the remainder of the pelvic organs. That is a very big cyst and another reason why they probably didn’t try to remove it. They’re going to drain the fluid out of it.
At this point, another trocar was placed suprapubically above the pubic bone at the time of the trocar incision. A small puncture was made into the cyst itself. Clear fluid began draining from the cyst cavity. That’s good to know. Right? It’s not part purulent there. No complications. So, they’re letting the fluid out into the abdominal cavity and it’ll be absorbed by the body or aspirate. An aspirator was then placed within the cyst cavity in approximately a hundred and fifty cc’s of absolutely clear fluid was drained from the cyst. Puncture site was not bleeding. Once the cyst was deflated, the rest of the pelvic pelvis could be inspected.
Uterus appeared normal. The right ovarian and fallopian tubes were visualized and appeared completely normal. This is all just good information at this point. They’re not doing anything else but draining that cyst on the left side. The other ovary was normal. The cyst was found to arise in a paratubular region and was not ovarian in origin. That’s good information. Not ovarian in origin. This is not an ovarian cyst. Okay? The cyst was nicely deflated and it was paratubal. The cyst was not excised. They didn’t remove it. That’s pertinent. This is all information that changes the way we code. It’s confirmed to be hemostatic. Remaining fluid was then aspirated from the cul-de-sac. That little area that everything sits in. The cul-de-sac appeared completely normal.
Upper abdominal was inspected and was normal. So, they’re already in there. They’re in the lower abdominal area. If they inflated the abdomen so they can look it around. They’ve made it like a big tent. They’ll go in and just double check everything. They’ll check out the appendix. They’ll check out the the gallbladder. They’ll, you know, peek at the liver and so on and so forth because they’re already in there. Why not? Appendix was visualized and was also normal. At this point, the procedure was terminated. The suprapeutic trocar was removed.
So, they start taking everything out. The abdomen was deflated. Suck out as much as that air as they can and then they take the trocar out of the belly button. That’s usually the largest one. The incisions were then closed with and again always pay attention. When they’re doing wound repairs and stuff the type of thread that is used. We don’t need to in this particular scenario. The vaginal instruments removed. The cervix was confirmed to be alright and the patient tolerated the procedure well. Everything was doing great at that point. There was no complications and there was no major blood loss. Okay?
Now, the contents. The fluid that was taken out was sent off and there was no malignancy and it says benign ovarian cyst. All right. Now, this is interesting. What is this tell us? Benign ovarian, excuse me, ovarian cyst but up here it says not ovarian in origin. So, that’s like what do you do? What what does that mean? Well, it’s very important because the pathologist is the final one to identify cells. And so, they were able to look at the cells and determine what the cells were. That being said, does that change the codes? Hmm, right? All right.
Now that we’ve broken this all apart, we know there wasn’t a lot that we really needed to pay attention to. We know the post was left large left ovarian cyst. The procedure was laparoscopic drainage and it’s a very specific type of cyst. Now, in our Advanced course, we would go in and show you what these systems look like, have pictures. We’d also let you talk about what’s paratubal means. It means around the tube and you know get a better idea how laptopic procedures were done and talk about the anatomy that we went over. It’s, again, more advanced. Right now, we’re just doing a case study where we kind of break down the abstract process and you can get an idea of our teaching style.
All right. So let’s talk about the codes itself. I went ahead and this is coded out for us. And so we don’t spend as much time live talking about this. I again it’s going to be staying up so that you have access. You can reference it at any time and let’s see what the codes look like. The first thing is it was a procedure that was done laparoscopically. That is very very important. Is it an open procedure? Is a laparoscopic procedure? Is it a laparoscopic procedure that was converted to an open procedure? Those are the questions that you need to ask yourself because that’s what the code said allows us to transfer translate for. So, we see here that we did a laparoscopic surgical procedure. And in addition, it was aspiration of cavity or cyst. Now, this is straight out of the code set and it states example of ovarian cyst and it doesn’t matter if it was one or multiple. You’re going to use the same code, right?
Now in our BHAT technique that Lauren created back in 1999, this is what it looks like. Everything after the semicolon, you highlight and very easy to replicate in your manual. Just know that with your CPT codes, everything after the semicolon you’re gonna highlight. So, does your eye goes there. So, we know that this is in the section of doing laparoscopic procedures, but this particular code 49322 is different than the others in that it has an aspiration and not just an aspiration. It’s of that cavity or and or the cyst. Okay, very very important.
And let’s see. Then let’s look at my favorite area. The ICD codes. This was a non-inflammatory disorder of the ovary, fallopian tube and broad ligament, but it’s other. When we use the ICD-10 code set, it states that other is defined by you have a diagnosis. There’s not a code for it at this time. So, the best code for this scenario is other non-inflammatory because there was no indication that those are flammatory and this was a problem with the ovary or fallopian tube and broad ligaments. It would all fall under there. Including in N83.8 is available what also cover Allen-Masters or broad ligament laceration syndrome. Okay,
Now, let’s look here. Key abstracting points. Shaneika, are we going over delivery one or speaking of global period? We are going to go over a delivery next and the, you know what, I don’t think. No, the global period isn’t mentioned in the one that we’re doing today. Very good point though Shaneika that you mentioned that. Thank you for bringing that up all. I’ll speak to it. When we’re abstracting the key points for a procedure like this is laparoscopic open or converted from laparoscopic to open and was the cyst removed. So, it was laparoscopic and no the cyst was not removed. The codes would change if those answers were different. That is our first case. So much fun. Right? I really enjoyed that.
Now, let’s jump over to our second case study which is going to be a cesarean delivery.
I mentioned earlier that this is kind of an introduction of how we do case studies and kind of open your eyes so that you can jump off with maybe some questions that you identify as we go through the process and come back and do more research or ask us to assist you with that. We’re not getting into an in-depth break-it-all-apart. That’s for our Advanced course. We have more time that we spend with this. This is a nice overview. So, this is the next case. It’s a cesarean delivery. Let’s just give that a look. All right.
Now, it’s noteworthy that as a particular provider, Dr. Martinez is going to only do the delivery services and tubal ligation. Very important the patient’s hometown physician is going to provide the antepartum care and also provided the postpartum care so or did provide the antepartum and is going to to do postpartum care. This gets very confusing if you’re not used to that because you’re thinking wait who’s taking care of what. So, that kind of leads to watch the NICU was stating. A global period, you know, the person that’s doing this procedure. The cesarean section is not the same person that took care of the rest of the procedure or the care of the patient. Again, we’re looking at a patient that is in-house. We have the attending and the surgeon is the same provider, Dr. Martinez. Let’s do did before.
Let’s break down the pre-operative diagnosis. Three prior cesarean section deliveries. What do we know about the abdomen and the uterus if you had multiple procedures done? For women of delivering age, especially cesarean sections, you can put it in the chat. What do we know happens to the body and why is it pertinent that the provider has documented this patient has had three prior cesarean section deliveries? Mmm, right Mary nailed it. Mary says scar tissue makes it much more complicated. So, going in they know this is not going to be an easy delivery, and the way I would say, ah, I thought of, sometimes I come up with analogies. May not be the best but picture this.
So, if you go to a restaurant and you order fried chicken if it’s a nice young bird, which most are if they’re delivered or if they’re bought commercially, right? It’s gonna be nice and tender. However, if you go and butcher your own chicken, and it’s an old rooster or chicken that no longer lays, what’s the difference going to be? In the two end results, it’s tough. Right? The chicken itself is not going to be as easy to work with and Shanika also mentioned adhesions. Scar tissue scarring. Devin said also scarring. So, this becomes very problematic. That uterus becomes leathery and to have to cut through scar tissue, it’s not like cutting butter. Have you ever had a tough steak? Again, I’ll quit that. Shame on me and doing those cooking analogies.
So, we have a lot of adhesions as the body tries to repair itself and compensate. We have scar tissue and scarring and we think well the outside of the abilene the skin doesn’t look too bad. No, we’re not talking about that because you can go above and below a line or cut a different way. We’re talking about what’s inside and so this could be very very difficult for the provider to get through. Yes, and Cindy makes a point. How previous ones were incision-wise. So again, did they go lateral laterally did they go, you know, which way was the decision and that’s why they make some decisions based on that?
Now, the next thing for the preoperative diagnosis is voluntary sterilization. So, the patient has decided we will go ahead and have a tubal ligation at the same time. Post-operative diagnosis. The provider states that it’s the same as the pre-op. So, that’s nice for them to state that so we don’t have to overthink that. So, what were the procedures performed? They did a repeat lower segment transverse cesarean section and they did a bilateral Pomeroy tubal ligation. We don’t really care that it’s Pomeroy. It’s a tubal ligation. Now, maybe someday there’ll be colds for those multiple types, but right now it isn’t. Just so you know.
Anesthesia different report they did general anesthesia. So, what’s the history here? Some of this will be pertinent to sometimes to the codes that we pick, you know, procedure and sometimes it won’t. So, it’s very important that you pay attention to what’s in that kind of area right there. It tells you why they’re doing, what they’re doing and a little bit of a history behind there. So, we have a 30-year-old woman who’s a gravida 4, para 3 and does anybody know what that means? I bet Shanika does because she’s obviously had experience with this. The reason they put that in there is it lets you know how many times the patient has been pregnant. Four times. How many deliveries and babies have been delivered? Three. Now, after this it’ll be four and four. Okay, and they also give the gestational age. So, it’s 36 weeks and two days. That is a little bit earlier, right? For 40 weeks is full term, but usually, 38 and 38 is considered full term.
And it says let’s see. So, two days gestation, it was 36 weeks and two days gestation, and they went in and initially went to her hometown obstetrician with spontaneous labor. Now, if they’re going to do c-section, they usually, and they know they are obviously in this scenario. They most likely knew that they were going to do it. They plan ahead and it’s very common when you’ve had multiple c-sections, you know, you’ve never had a vaginal delivery and there’s coding for a previous c-section to vaginal delivery. But here we knew that this patient was going to be scheduled for a c-section, but guess what she wanted 36 weeks and so she goes into labor and if they know you’re going to have a c-section and you go into labor before that date, that’s a problem.
So, because of her history with the previous C-sections, he’s sending her off to the surgeon. And so, they transfer her, and thus the surgeon is not involved with the pre and post-care for that patient. She scheduled to have a repeat cesarean section. She also expressed the desire to do the permanent sterilization and she’d signed all the paperwork for the tubal ligation. So, what do we know here? We’re doing sterilization. Let’s go ahead and highlight that in our codes and we’re doing a cesarean which again we already know that because that’s in the title. Right? Let’s see now. She was sure of her decision for the tubal ligation. Why would you put that in your procedure report? Because it’s a legal document and they don’t want the patient. I can say I didn’t want that even though I signed the paper. I was too upset and nervous and I was in labor and everything. No, she understood her decision and the provider has stated that she acknowledged that.
When she presented, she was having contractions every two minutes with moderate intensity. That’s pretty close together. If any of you guys have had children before the cervix was not dilating yet. So, this could be for multiple reasons. Maybe the body just hasn’t kicked in but if you’re having contractions every two minutes and your cervix hasn’t dilated yet, that’s a little wonky. That’s not necessarily what you want to see. They know, now she was not previously C-section and she was gonna do a vaginal birth. They probably would have done something to help open the cervix. There’s cream. There’s a medication that they can use. They can give misoprostol and a bunch of other stuff and they would just let her labor that out a little bit longer but no we can’t do that. This patient is gonna have a C-section and they don’t necessarily want the cervix to open up.
So far, that’s okay, but it’s noteworthy. This cervix isn’t dilating. With the intensity of the contraction, the decision was to go ahead and do a c-section because they might have given her something just to stop the labor. They can do that and say let’s give it another, you know, 24-48 hours and see if we can get another day in for the baby. 36 weeks is okay. But again, there are a lot of reasons that could be a part of that and if you are commonly doing these types of reports, coding them out, you’ll see all the reasons. You’ll know those.
So, the procedure note. Now, we’ve got all of the behind-the-scenes. We know why they’re doing, what they’re doing and we know we’re doing two procedures. We’re going to do a c-section and it’s not just any section. It’s a C-section after C-sections and we’re going to do the tubal ligation. So, what do they do? Let’s see. What’s not fodder in this one. So, the patient goes into the operating room. They do a spinal. The patients then prepped and draped and everything is taken care of. Note, they also do a left lateral tilt. That’s pretty common, too. Carmen makes another point. Can have complications if born prematurely. That’s true. Note that if there are complications with the baby, that goes on the baby’s chart not on the delivery. Okay? Keep those if there’s a complication to the delivery. It’s here in this report. But once that baby is removed from its mama, the baby gets its own chart. So, they place up Foley catheter. That’s very very common.
So they do a, let’s see, a fan and style skin incision and they do it superior to the pre-existing scar. Sometimes providers will try to stay right there within the scar that they had. Again, there’s a lot of finesse to the way different doctors do what they do and how much time they have to do what they do. But for the most part, they tried to keep the abdomen as free of multiple scars as possible. Now we’re going to start breaking down getting into the baby. DJ, you make a good point. Should spinal procedure have been highlighted? We can however that’s part of anesthesia. So, it’s not going to be coded here. That’s in an anesthesia report. Very good point to bring up. Glad you did because I failed to distinguish that so I’m not going to do that.
And again, anesthesia handles the spinal as well as general anesthesia where they put you under completely. It’s got to be noted in the procedure here because they’re working as a team, but it will be its own report. So, they do the transverse section and actually when you go in and do these C-sections, they go in layers, so they open up the top layer and then they look to see where they’re at then they go into the next layer and then they do another layer until they get to the uterus. So, let’s see the fascia show was in size meaning they’re getting into the top of that skin. The peritoneal cavity was then carefully entered as the bladder was pulled up quite high interiorly.
So if you get the opportunity, you can go online and you can see cesarean sections being done and how they do that. It’s not done like you think if you’ve never seen it done before and what they’re going to do is they have to be very careful because when they do this and they go layer by layer and then the bladder and the uterus are right there on top of each other. So, they’ve noted if anything’s gonna go wrong it’s gonna be a hemorrhage or they’re gonna mix something. Definitely, don’t want to cut the bladder. So, they find the bladder and they get it out of the way with the retractor then a transverse incision is then made in the loader uterine segment. So, here’s this bulging uterus with the baby in it and then go down to the bottom of the uterus. Not here on top like you would imagine but down on the bottom and there was the delivery of a live-born male infant and then they’ve got Apgar of 8 at 1 minute and 10 at 5 minutes and weighed 5 lbs 8 ounces. Now, this information all right here we want live born that’s important to this but this is all important. to the baby, not the Mama’s chart. Okay? Differentiate that.
The Apgar score, that’s the baby. That’s all in the baby’s chart. Not the mama. Also, the weight of the baby goes on the baby’s chart, not on the Mama’s chart. All we care about is the baby was delivered and the status of the baby when it was born. It was born live. The baby was suctioned on the table immediately. Handed over to the neonatal intensive care team because the babies, you know early then they have to take care of the placenta. So, they remove the placenta and everything and then they’ll inspect it. It appeared to be intact. At this point, the uterus exteriors are raised to allow for better visualization. Meaning they took the uterus out and kind of gave it a once over. The uterine incision was closed and they just did a single running lock layer and this is the type of dissolvable thread that they use. Everything, he must state everything was good.
Okay, again, remember we’re splitting it up. Baby chart now and Mama’s chart. Let’s see Sandra says can we please have a YouTube session on how to code anesthesia? Absolutely. I think that it was already posted on how to do a topic request. Please do that for us. So, we can begin the record. Normally, there is an assistant surgeon. Also, Cindy makes a very good point. One doctor surgeon doesn’t just go in there and do all this. This is intensive, you know, and you really need more than one set of eyes. So, it is a team that works. You have to have the team for the mama. You have to have a team for the baby. You have to have then you have specialist if it’s something’s abnormal for the baby and they know, you know, potential abnormal for early then we have the surgeon, their assistant and then, you know, then there are other clinicians that are in there. So, it’s quite the rigmarole but they’ve done it so often that usually they’re a well-oiled machine. Everything goes smoothly and they’ve practiced and they’re prepared if anything is not going to happen the way it should.
All right at this point, attention was then directed toward the fallopian tubes. The babies delivered that procedure is done. They’ve taken care of it. Now, they’re gonna take care of the, oh what am I trying to say, sterilization. Okay, so then they go find the fallopian tubes. Now, there are a lot of ways to do this and this is provider preference. Sometimes, they talk it out with the patient, you know, and you mean I would want to know how they’re gonna do it to me, but you know, they’ll they’ve cut them. They nod them. They clamp them. They suture them. I mean there’s just sometimes they do lots of things but it’s a preference to what procedure they do.
So, both ovaries and fallopian tubes are identified. They look normal. Good to know. They grasp the fallopian tube with a Babcock clamp. They do a bilateral Pomeroy tubal ligation which is a specific type and was carried out by tying off a loop of the tube with plain suture and then excising in the intervening portion of the fallopian tube bilaterally. Excising so they do not cut it. Good hemostasis. You definitely don’t want to have a bleed here.
That’s how women bleed out. When they have an ectopic pregnancy, it ruptures and they bleed and we don’t, you know, they don’t catch it, and the abdomen fills up with blood. So then now at this point again, so we know that they did bilateral tubal ligation. Let’s get that. Okay? The uterus was replaced within the peritoneal cavity. So, the whole time the uterus is sitting there, right? They go with it which again gets the uterus out of the way. They can take care of the fallopian tubes. Pop that uterus back in there. Pericolonic gutters were swabbed free of blood and clots. Making sure that they’re not going to have any problems there.
The uterine incision was once again inspected to confirm that it was okay. So, they’ve already stitched the uterus closed, and again during this whole time the uterus is starting to clamp down because the baby’s gone. So, it’s going through some major changes as well as having the stitches. Now, they’re going to start sewing the mama up from the inside out those different layers. So, they closed up the fascia then they close the skin and you know that because of the different types of thread that’s being used. Okay, and where it’s done, so the patient tolerated the procedure. Well, they went into recovering. Good condition. There were no complications and minimal blood loss and they went ahead and gave the patient Ancef which is after they clamped the baby’s cord. Standard procedure. S
So let’s look. DJ says so does each medical technician surgeon and others each have separate codes for their independent claims. No, they do not. No, they don’t. Now if you’re in a teaching hospital, maybe in staff, if there are major complications because it’s a team, let’s say this was quads, you know, we’re having five babies or four babies would be quad.
Where’s that five? I don’t know. Maybe say they’re having trouble. Let’s quit messing with my mind. That’s what I’m telling myself. Okay, if you’re gonna have multiple babies and stuff that gets into teams, and that could involve modifiers and stuff or maybe they knew that the baby, one of those conjoined twins there. That’s gonna be a problem. Stuff like that. So yes, there are incidences where, you know, they will do different reports but for a standard delivery like this, no. One takes care of it. Very good point Thank you DJ for bringing that up.
Cindy says important to check path report to confirm both tubes were done for verification purposes. Another excellent point. The pathology report would come back and that would be put in the mother’s record that was confirmed. So, you can tell we’ve got practical applications. These people have experience and thanks for contributing and sharing your knowledge.
So, what was done? We did a cesarean delivery only. By itself, it would be 59514. It’s not very fancy. Okay? Simple cesarean delivery. 59514. When you say well, how come it says only? Well, sometimes what happens is they try a vaginal birth. It doesn’t work and they revert to a cessarian. Okay, and so there’s code specifically for it those and scenarios. We want to tell the whole story. We’re just translating what happened. Next, they did the sterilization. 58611 states that we did tubal ligation when done at the time of cesarean delivery or intra-abdominal surgery. So, if they’re in there already then that’s telling them hey, you don’t get extra funds for doing a ligation like this if you’re already in there doing another procedure. That’s why 58611. If you go look out at what it pays out, it’s not going to pay out as much as if the patient came in and that’s all they were doing. So you don’t get to double dip on the opening up the patient or even if it’s laparoscopic. That’s why it’s important and this code is unique.
Again cesarean delivery, what do we do? That’s all we did was we did the cesarean and then if we had done more like she started out trying to do a vaginal and we had to convert to the cesarean or you know, there’s a list there then and the ligation, the tubal ligation, it was unique. Cindy says sterilization is an add-on code. No modifier. Excellent. Also, real-world note for you, guys. And then DJ says that’s called double dipping A and then no, no. You’re right DJ. You can’t do that and the cost won’t allow you to do that if you pay attention to the NCIS edit those things, okay? So, now we have very very simple two codes for the procedures. But what about the diagnosis? This is where everybody gets a little nervous and there are a lot of codes but really we’re taking it step by step and telling the whole story through the diagnoses. Fun stuff. Okay?
One at a time. The patient was preterm. That’s noteworthy. We know that 36 weeks and we even need to know to what extent. So, the patient is in preterm labor third trimester with preterm delivery third trimester and there’s only one fetus. So there will be that last character tells you if it’s how many fetuses it could be. One two, three, four five. You can just keep going. So, it’s O60.14X1 because there’s one baby and then we have maternal care for an unspecified type of Scar from previous cesarean delivery. Okay? O34.219. That one gets overlooked a lot. Then we have a single life birth Z37.0 and then the last encounter for sterilization Z30.2. This is the Mama’s chart. Now. The baby will have established their own chart and you’ll be coding probably side by side. The mama and the baby. When you’re new at this it kind of can get confusing. Don’t overlap those codes and everything.
Cindy said that I love diagnose coding OB. You know what? It is fun and the reason it’s fun is because you literally see this story being told in the diagnosis. Right? I mean, it’s repetitious, too. Before you know it, you got these codes practically memorized. I bet Cindy would say. Let’s see. I may not say your name, right, Tenia? Tenia. Why wouldn’t you assign O34.211 instead? Well, let me show you and I just happen to have my own encoder up and I’ll show you. Excellent question. So, let’s see. O34.211. Let’s just pull that in so you can see what the code is. Give it just a second while it’s thinking. It states maternal care for low transverse scar from previous cesarean delivery. Ah, but look. We have this one. O34.219 Maternal care for unspecified type Scar from the previous cesarean. They don’t tell you what the previous scar was in the report. So, they just tell you what type of incision they did. This time I don’t think in the report that it told us what the previous scar was. We could double-check. Was made superior to the pre-existing scar. So, they don’t tell us what type it was but they made a transverse incision. Good point.
What about the weeks of gestation? The weeks of gestation are built into this code right here where it says preterm delivery third trimester and from that point everything else gets put on the baby’s chart. So, Cecilia another great point. They don’t say it’s 36 weeks. We just know 36 weeks third trimester but it’s preterm. So, you got it. 38 to 40 is not but anything, you know, if you know when the third term starts, just top on my head I can’t remember and you’ve divided it up, you know in three ways. Zero to 12 weeks. 12 to 24. 20-25 That doesn’t seem right. 32. I can’t remember. Oh I should have looked that up. But the good news is if you take the advanced course we talk about all of that and we break it all down and give you the information that you need to know behind the scenes. Thank you, Cecilia. 28 weeks, 28 weeks.
Any other questions? The abstract in questions for this case would be did they do the tubal ligation report separately? Yes, within the report they separated it. Is the history of the previous C-section reported? Yes. They did. And is a Z code required for the tubal ligation? Yes, it is. So, those are the main takeaways for this particular one.
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That being said remember if you have a particular question or something you want us to unpack and go over it in a live webinar like this, our CCO live, let us know. If you’re part of our club, put it in the club and you always get, you know, priority as our students. DJ says are there software programs on the market to proofread your complete analysis of medical claims and billing before it’s finalized to make sure that everything is proper? Yes, there is and it’s called a clearing house. They have clearing house programs Cindy, yes. Also, live birth. Yes, we got that one. Did the advanced class start yet? It has launched. Sign up tonight at midnight. It was either last night or tonight was the last day to save that extra hundred dollars on the course and check out that link. It’s gonna be fabulous Carmen. I know you will like it because I know you.
Alright, topic requests. And I think that’s it guys. Hopefully, this was enjoyable, and you’ve learned a lot. I really appreciate Cindy adding her insight and those of you who have also made comments. Really appreciate that. One of the great things about our CCO Live is that it is casual and interactive and we can bounce knowledge off of each other. I know that I learn stuff all the time from watching the comments. Make sure that you double-check our other platforms. We’re on of course YouTube, and LinkedIn and you can find me on LinkedIn as well as CCO, Facebook, and now we’re on TikTok and Instagram and we’ll start popping out some fun stuff. If you were not already following us on those platforms, tell everybody. If this was helpful for you, share. We advertise via word of mouth. I think that’s the best way to do it. And let everybody know we have that advanced class coming out. We love what we do because we think learning is fun. And so, I hope that our teaching style resonates with you. All right, guys. Have a great rest of your day.