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Ob-Gyn Coding Alert

You Be the Coder:

Reporting Dilation and Curettage

Question: The ob-gyn admitted a patient who had dysfunctional vaginal bleeding for three weeks. He performed a dilation and curettage (D&C). Should I report 57800 or 58120? I also assigned 626.8 and 285.1 as the diagnosis.

Alaska Subscriber

Answer: Don't use 57800* (Dilation of cervical canal, instrumental [separate procedure]). It does not sufficiently describe the procedure the ob-gyn performed because it portrays only half of the work. Instead, you should use 58120 (Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) to show  more clearly what the physician did.
Although 285.1 (Acute posthemorrhagic anemia) may be an appropriate diagnosis code, 626.8 (Disorders of menstruation and other abnormal bleeding from female genital tract; other) probably is not specific enough for this example. Instead, you should use 626.2 (Excessive or frequent menstruation). If the bleeding is bad enough for the ob-gyn to take the patient to the operating room, it likely is excessive.