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how to file a D&C that was done in the office without anesthesia

Rosi Posted Thu 20th of May, 2010 18:56:44 PM

A patient came in the office with heavy bleeding and about to lose the product of conception, the doctor did a D&c in the office.I had problems before to get it paid and don,t want to go thru all the hassle again to make the insurance understand it was done without anesthesia. What codes will I use?

SuperCoder Answered Fri 21st of May, 2010 06:04:44 AM

It seems the patient has either missed or incomplete abortion, you need to ask the physician about the final diagnosis and trimester. As per that it can be coded from 59812-59821.
If the pateint comes with some other general non-ob problem and the physician performs a D&C then you can code 58120 in this case.

SuperCoder Answered Fri 21st of May, 2010 08:02:27 AM

D&C procedures are performed with anesthesia, for most of the time. General, spinal or a local anesthetic is used based on patient's medical condition and willingness. performing curettage of uterus and cervix without any anesthesia may cause discomfort and pain to the patient. But as your doctor has performed the Px w/o anesthesia and in the doc's office only, we may assume that it was done because of emergent situation. As per the choice of code is concerned, I second Alex, except 58120. It's an obstetric case only and so 58120 is not a code of choice here. You may require to submit the OP notes along with the claim to prove that the case was urgent and of utmost medical necessity.

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