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Susan Posted Sat 27th of October, 2012 23:06:32 PM

Can you please tell me what is the cpt code for ring forceps removal in the office and also in the hospital. Diagnosis is postpartum bleeding and retained product of conception.

SuperCoder Answered Mon 29th of October, 2012 13:25:21 PM

Case 1: The ob-gyn treated patient A, at 19 weeks, in the clinic without anesthetic. She had aborted spontaneously but was still having minor bleeding after a few days. Some tissue was visible on exam, so the ob-gyn removed it via ringed forceps.

Case 2: The physician gave patient B, at 17 weeks, misoprostol. She delivered a nonviable fetus but the placenta was retained. She was treated in the birthing suite with IV sedation, also with ringed forceps to grasp the retained tissue.

You can consider these to be "reduced services" for the existing codes for surgical treatment of abortion.

If this were a spontaneous incomplete abortion, you would code 59812-52 (Treatment of incomplete abortion, any trimester, completed surgically; reduced services) for the removal of the products with ring forceps. If this were a missed abortion situation, then you would report 59820-52 (Treatment of missed abortion, completed surgically; first trimester; reduced services) or 59821-52 (… second trimester; reduced services).

You would not be removing products in this fashion for a septic abortion (59830, Treatment of septic abortion, completed surgically) due to the risk of leaving something behind.

Bottom line: You should use the surgical codes (rather than an E/M service) to report this type of procedure. Why? The surgical codes more accurately capture the physician work, practice expense and malpractice expense (in the sense that the ob-gyn performed an intervention which involves some risk).

If the physician has documented a separate and significant E/M service for evaluation of the spontaneous incomplete abortion, you can also report an E/M service with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) attached. This does not represent global care.

Susan Posted Mon 29th of October, 2012 16:54:29 PM

Thanks for your respond. The patient delievered vagnially when she came for postpartum visit the doctor had to do ring forceps removal. what is the correct cpt code?

Susan Posted Thu 01st of November, 2012 20:53:33 PM

can you please respond to that question or send it to editor?

SuperCoder Answered Thu 01st of November, 2012 21:03:06 PM

This has been answered few months back by our editor. The answer was

If the "retained product of conception" is Placenta, Report 59414.
You may check the code range 59400-59430 for the specific CPT code based upon your operative notes.

Please confirm do you still want to refer this one..

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