A difficult area of ob/gyn coding is that of selecting the right ICD-9 and CPT codes for the interruption of pregnancy and stillbirth. There are numerous coding choices which will be determined by what you learn from the physician and the documentation concerning the following five issues in the order listed.
1. Identify the cause and/or reason for the interruption of the pregnancy. This will help you determine which diagnosis code to select. Within the ICD-9, the following illustrates some examples of the differentiation between types of abortion. Note that many of these codes require additional digits, which are indicated by an X:
Missed abortion: 632
Intrauterine death: 656.4X
Threatened abortion: 640.0X
Complete or incomplete (spontaneous) abortion: 634.XX
Legally induced abortion (elective, legal, therapeu-
2. You need to know at what point the pregnancy was terminated. This can be an important distinction, as some state legislatures have legally defined the difference between a miscarriage and a stillbirth by the number of weeks: i.e., 16 weeks, 20 weeks or 22 weeks, or by gram weight. This legal definition may determine which CPT codes (i.e. abortion vs. delivery codes) are appropriate for the insurer.
Tip: Your physicians should know the state definitions regarding stillbirth and miscarriage, but if you have questions, a good source for these guidelines would be your state medical examiners office.
3. Identify what services, exactly, were rendered in treating the patient. Where were they performed (office, hospital, or other facility)? As usual, CPT codes cannot be selected until the exact services rendered are documented.
4. Determine whether the patient was in labor before treatment was begun. If so, was labor enhanced, or, was the abortion induced?
5. Finally, at the time treatment begins, the physician must determine and document whether the products of conception were already expelled and whether or not the expulsion was complete.
ACOG Coding Recommendations
Once these questions are answered, then you can begin identifying and selecting the correct CPT codes for the services rendered. The American College of Obstetricians and Gynecologists (ACOG) Committee on Coding and Nomenclature has developed the following coding recommendations for termination of pregnancy:
Surgical management (i.e., D&C or D&E) of incomplete abortion. Defined by ACOG as the expulsion of some products [...]