If you label a nonelective abortion as "complete" or "incomplete," you may automatically establish your CPT® coding options for the ob-gyn's services, regardless of what he or she may have done.
Generally, you will designate nonelective abortions at fewer than 22 weeks gestation as spontaneous incomplete (634.x1), spontaneous complete (634.x2) or missed (632). [Update: This changes to less than 20 complete weeks in ICD-10.] Although technological advances enable physicians to detect pregnancy in its earliest stages, coding for nonelective abortions has become more complicated.
When a patient presents with no prior pregnancy diagnosis, the ob-gyn can use tools such as ultrasound and beta subunit HCG (human chorionic gonadotropin, a pregnancy test that helps determine the stage of pregnancy) to confirm pregnancy and decide how far it has progressed. When a patient presents with a nonelective abortion, diagnosis and procedural coding can be a challenge, especially if the pregnancy terminated very early on.
Women frequently do not seek medical attention for a delayed menstrual cycle because they may not be aware that conception occurred. If the ob-gyn diagnoses a pregnancy and it later terminates, either spontaneously or by induction, you should report the related physician services. And the diagnosis coding can be critical to ensuring proper payment for the doctor's work.
Patient's Diagnosis Affects CPT® Coding
When determining the correct CPT® code for treating a nonelective abortion, the first question is whether the ob-gyn performed surgery to complete the process. If the patient presents with a complete spontaneous abortion [Update: (and ICD9 rules mandate this is known at the start of the visit)], no products of conception remain in the uterus. You would likely report an E/M code (99201-99215, Office or other outpatient visit ...) because he doesn't perform any type of procedure to treat the patient's symptoms, coding experts say. You would link the E/M service to 634.x2 on the CMS-1500 form.
If the patient has an incomplete spontaneous abortion, however, she would still have products of conception retained, though they may be expected to pass naturally without surgical intervention. If the products of conception do not evacuate on their own, the ob-gyn may perform a dilation and curettage (D&C). In this case, you would submit 59812 (Treatment of incomplete abortion, any trimester, completed surgically) with the incomplete spontaneous abortion diagnosis (634.x1).
But, if the patient has a missed abortion, products of conception always remain in the uterus. As with incomplete spontaneous abortions, the ob-gyn may have to evacuate a dead embryo or fetus from the uterus through D&C. But in the case of missed abortions, you would report 59820 (Treatment of missed abortion, [...]