Question

A patient with a previous low transverse incision cesarean delivery is attempting VBAC (vaginal birth after cesarean), also known as TOLAC (trial of labor after cesarean) with her second child. During labor her uterus ruptured. She had an emergency cesarean section followed immediately by hysterectomy to remove her ruptured uterus. Mother and baby survived. The same obstetrician provided her antepartum and postpartum care. What are the CPT® and ICD-10-CM codes reported for this service?

Answer 1

A patient who attempted VBAC experienced a uterine rupture and required an emergency cesarean and hysterectomy, with CPT® and ICD-10-CM codes needed to document the procedures and diagnoses.

Step-by-step explanation:

A patient who previously had a low transverse incision cesarean delivery is attempting a VBAC (vaginal birth after cesarean) or TOLAC (trial of labor after cesarean). Unfortunately, the patient experienced a uterine rupture during labor and underwent an emergency cesarean section followed by a hysterectomy to remove the ruptured uterus. The same obstetrician provided the antepartum, delivery, and postpartum care for the patient. In this scenario, coding for these services would include CPT® (Current Procedural Terminology) codes for the emergency cesarean section, the hysterectomy, and the postpartum care, as well as ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) codes to reflect the patient's diagnosis, including the previous cesarean section, the attempt at vaginal delivery, and the uterine rupture.