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diagnosis and procedure for doing a bedside manual extraction of retain POC

Stacey Posted Tue 17th of March, 2020 18:25:34 PM
How do I code for diagnosis and procedure for doing a bedside manual extraction for retained products of conception when the delivery was done by another doctor?
SuperCoder Answered Wed 18th of March, 2020 07:14:29 AM

Hi Stacey,

Whenever a patient has retained products of conception after a therapeutic/elective abortion, ICD-10 rules consider the patient to have had a failed abortion. In this case, because the patient had an elective abortion, the correct diagnostic codes would be O07.4 (Failed attempted termination of pregnancy without complication) and Z33.2 (Encounter for elective termination of pregnancy) even though your physician did not perform the initial procedure.

NOTE:

The diagnosis will be incomplete abortion, not missed abortion for the repeat. If the procedure had been done more than 90 days following the initial surgery, a member of the ACOG coding committee has recommended using CPT  58120 (Dilation and curettage, diagnostic and/or therapeutic (non-obstetrical)).

So, this would be CPT 58120 with modifier 78. And ICD-10 as O03.4 (Incomplete spontaneous abortion without complication).

Feel free to ask for any further query.

Stacey Posted Wed 18th of March, 2020 14:55:54 PM
This was an actual delivery of live baby. Dr. was doing her rounds and patient was still bleeding and Dr. noticed she still had fragments of the placenta in her cervix. Modifier 78 indicates return to operating room which she didn't, it was in her patients room at bedside. Would we still use this modifier? Thanks
SuperCoder Answered Thu 19th of March, 2020 08:30:33 AM

Hi Stacey

If fragments of the placenta in cervix after delivery of live baby were removed manually in patient’s room then we will not use modifier 78. For the above scenario we will use ICD-10, O72.2 (Delayed and secondary postpartum hemorrhage)and CPT 59160 (Curettage, postpartum). Feel free to ask for any further query.

Stacey Posted Thu 19th of March, 2020 09:39:38 AM
Thank you for this.
SuperCoder Answered Fri 20th of March, 2020 01:34:02 AM

Thank you, happy to help.

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