Is adhesion formation reduced after laparoscopic myomectomy? … and more
Gerald L. Vitamvas, MD
Milwaukee, Wisconsin
Dr. Barbieri responds Pay attention to the shoulders
I agree with Dr. Cintron that the fetal shoulders should be delivered with attention and care. In my experience, all obstetricians take great care in delivering the head across the perineum to avoid lacerations. Not all obstetricians focus as much attention on gentle delivery of the shoulders; this lack of attention can increase the risk of perineal laceration.
I deeply respect the clinical experience and insights of Dr. Vitamvas, and I agree that a median episiotomy is better tolerated by the patient. I wonder if he would consider performing a mediolateral episiotomy occasionally during operative vaginal delivery? A recent article concluded that, in this setting, a mediolateral episiotomy is associated with a sixfold reduction in the odds of developing an obstetric anal sphincter injury, compared with a median episiotomy.1
Q. What CPT code should be reported when the Bakri balloon is used to stanch postpartum bleeding?
A. Placement of the Bakri balloon to control postpartum bleeding does not have a specific Current Procedural Terminology (CPT) code. However, the additional work involved should be captured so that you can be reimbursed by the payer. I recommend two options:
- If the patient has not been sent to recovery when the bleeding is noted, simply add a modifier -22 (increased procedural services) to the delivery code.
- If the bleeding is noted after the patient has been moved to recovery, use the unlisted code 59899 with the modifier -78 to reflect a return to the operating room or a procedure suite.
If you use the modifier -22, be sure to document the reason for the additional work and the length of time it took to stop the bleeding. please refer to the CPT guidelines (in the CPT book) for use of this modifier.
If you use the unlisted code 59899, you need to link the work to an existing CPT code so that the payer can determine whether your charge is reasonable. For instance, a similar scenario might involve code 43460 (Esophagogastric tamponade, with balloon [Sengstaken type]) to control variceal bleeding. this code has 6.65 relative value units (RVUs). However, if the bleeding is controlled quickly, it might be better to use code 46604 (Anoscopy; with dilation [eg, balloon, guide wire, bougie]), which has 1.94 RVUs, or code 51703 (Insertion of temporary indwelling catheter; complicated [eg, altered anatomy, fractured catheter/balloon]), which has 2.41 RVUs.
This is one of those times when you must not only document the work you perform but feel comfortable setting the charge for that work. in other words, be prepared to defend your choice when you select a code to support your charge.
—Melanie Witt, RN, CPC, COBGC, MA
Editor’s note: Ms. Witt is an independent coding and documentation consultant and former program manager, department of coding and nomenclature, American College of Obstetricians and Gynecologists.
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