Sharmilla Posted Mon 27th of June, 2016 15:53:14 PM
I am not clear if I should be coding CPT 59820 looking at 10 6/7 weeks missed abortion or should I code 59821 since the gestational age found on ultrasound is 17/07 weeks.
Secondly, should the dx be missed abortion or IUFD?
Please see operative note below
Preop Dx Intrauterine Fetal Demise @ 10 6/7 weeks
Postop Dx same
Procedure Exam under anesthesia, Dilatation and suction curettage
Indications: 17 0/7 weeks gestational age found on US to have a missed abortion at 10 6/7 weeks. She elected to undergo definitive treatment with dilation and curettage. Consent was signed with patient and all questions answered.
Operative report: Patient was taken to the operating room where she received general anesthesia. She was then placed in dorsal lithotomy position with her legs in the candy-cane stirrups.
A surgical pause was performed immediately prior to start of procedure where all members of the surgical team confirm pt ID, planned procedure and voiced any concerns.
Exam under anesthesia revealed a 12 weeks sized uterus, that was mobile and anteverted. She was then prepped and draped in the normal fashion and bladder emptied in a sterile manner.
A sterile speculum was placed in her vagina and the cervix visualized and grasped with a single toothed tenaculum on the anterior lip. In a stepwise fashion, her cervix was dilated with the Hegar dilators to 9 mm. The 9 mm curved suction curette was placed into her uterus and suction intitated. Multiple passes were made and tissue removed. A gentle sharp curettage was performed to ensure grittiness of all four sides of the uterus. One remaining pass was made with the suction curette for removal of all clots and debris. There was noted to be minimal bleeding and the tenaculum was removed and the sites inspected for excellent hemostasis. Speculum was then removed and the patient cleaned.
Sponge, lab and needle counts were correct x 2. In addition, clear count automated sponge counting system was used to confirm correct count.
She had received Doxycycline 100 mg IV prior to the procedure
SuperCoder Answered Tue 28th of June, 2016 03:48:22 AM
When performed with quality and precision, ultrasound alone is more accurate than a certain menstrual date for determining gestational age. So, use CPT code 59821, Treatment of missed abortion, completed surgically; second trimester. Also, the diagnosis here would be missed abortion as the fetal death occurred before 20 weeks of gestation, and would be coded as O02.1
Hope this helps!