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“CODE THIS!” (Case of the Month)Placenta Only Delivery, Repair and Curettage by Lori-Lynne A. Webb, CPC and Renée Allen, MD, MHSc., FACOG Case Excerpt (summary and narrative of actual case): Comments Brief Note The OBGYN hospitalist was requested to be present and supervise the last hour of the second stage and attend the vaginal delivery of this Certified Nurse Midwife’s (CMW) patient, a 35 y/o G1P0 female at 39 6/7 week gestation. The Hospitalist was informed that variable decelerations were noted during the active phase of the labor and increased in frequency during the second stage of labor. Upon arrival into the delivery room, the OBGYN Hospitalist noted that the patient was pushing with good effort. The fetal vertex was at +2 station and straight OA. It was decided to have the patient push with every other contraction to allow for a longer recovery period between expulsive efforts. In the last 20 minutes of the second stage, the Hospitalist noted that there were variable decelerations to the 90's even between contractions. The Hospitalist discussed the option of a possible vacuum assisted delivery due to the frequent variable decelerations but the patient was reluctant to proceed with the operative delivery and instead continued her pushing efforts. The patient’s expulsive efforts were able to bring the baby to crowning at 00:22 and the CMW delivered the fetal vertex over an intact perineum at 00:25. The shoulders and body delivered very quickly thereafter. The baby was placed on the mother's abdomen but the pediatric nurse noted that he had no tone or respiratory effort so the NICU team was called immediately and the baby was taken to the warmer. The baby's HR was >100 initially but he was not making spontaneous respiratory effort. PPV was initiated after the first minute of life as the newborn’s heart rate fell to under 100 but the hospitalist and pediatric nurse had difficulty getting an adequate seal on the mask, so there was no chest rise noted. The NICU team arrived at 2.5 minutes of life and assumed care of the baby. His APGARS were 2 and 8. The newborn was subsequently taken to the NICU due to grunting . The arterial cord gas clotted but the venous pH was 7.29 with Base Excess 5.0. The placenta did not deliver spontaneously. The bulk of the placenta was in the vagina but appeared attached by an edge. The placenta was manually extracted without difficulty with trailing membranes noted. The placenta was noted to be circumvallate with a pseudoknot in the cord. A large clot followed the placenta but the uterus was firm and bleeding was minimal thereafter. A manual sweep of the uterus was performed with additional membrane fragments removed. The ultrasound was brought into the room and an ultrasound imaging performed by the OB/GYN Hospitalist demonstrated remnants of placenta still contained within the uterus. A bedside curettage was performed under ultrasound guidance with 3 passes of the curette with only a small amount of clot removed. The endometrial stripe appeared normal following the curetting measuring 0.8 to 1.4cm. Overall the procedure was very well tolerated by the patient under epidural anesthesia . IV Unasyn 3gm X once was given for postprocedure antibiotic prophylaxis. The vaginal and labia were inspected to reveal a posterior vaginal wall laceration that was just a few centimeters in length and a small left labial laceration, second degree . The vaginal laceration was repaired with a 3-0 Vicryl running, and the labial laceration was repaired with 4-0 vicryl running. Of note, the patient had a prior history of labial cosmetic surgery and has minimal labial minora and vertical scars along her bilateral labia majora.
As the OB hospitalist, how would your services be coded? Answer: ICD 10 Diagnosis Coding considerations include:
CPT codes CPT 59414 Placenta Only Delivery
CPT 59160-51 Bedside Curettage (with modifier 51)
CPT 76998-26 Bedside Ultrasound (with modifier 26 (professional component)–reading and interpretation by physician only.
CPT 59300-51 Repair Procedures for Maternity Care and Delivery (with modifier 51)
Coding Brief
The OB/GYN Hospitalist, in this case, correctly assigned the diagnosis code of O73.0 Retained Placenta without Hemorrhage and O70.1 Second Degree Perineal Laceration during Delivery after a thorough pelvic examination and ultrasonographic evaluation was performed by the Hospitalist.
The delivery of the placenta by the Hospitalist should be coded using CPT Code 59414 – Delivery of Placenta. This CPT code should only be reported when the procedure is done separately from the routine delivery:
The OBGYN Hospitalist should bill for the bedside ultrasound performed, read and interpreted by the Hospitalist using the CPT code 76998 with modifier 26.
The Hospitalist determined the patient had retained placenta that needed to be managed by curettage, of which the Hospitalist gently scrapes the endometrial lining of the uterus to control bleeding, treats obstetric lacerations, or removes any remaining placental tissue.
This procedure should be coded using CPT code 59160 Scraping of lining of uterus post-delivery CURETTAGE POSTPARTUM. Since the postpartum uterus has been previously dilated during delivery of the newborn, dilation is not required for this surgery. This code is only to be used for postpartum curettage.
The vaginal and left labial repairs performed by the Hospitalist during this case should be billed using:
It is important to discuss modifier 51 in this case scenario. Modifier 51 - Multiple procedures - should be employed to show that the same provider performed multiple procedures (other than E/M services) during the same session. List the most resource-intense (highest paying) procedure first, and append modifier 51 to the second and any subsequent procedures.
Modifier 51 indicates:
Payers usually apply a "multiple procedure discount" with modifier 51. This reduces the reimbursement for subsequent procedures because resources are shared when two or more procedures are performed together.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 CM/PCS Ambassador/Trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at or you can also find current coding information on her blog.
Dr. Renée Allen served co-author of this column. She is the SOGH Liaison to the ACOG Committee on Health Economics and Coding and Co-Chair of the Development Committee. She currently works as an OB/GYN Hospitalist with Mednax/Obstetrix at Eastside Medical Center in Snellville, Georgia.
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