louise Posted Fri 29th of March, 2019 07:12:41 AM
21 year old LSIL pap who presented to OGES with lower abdominal pain, found to have inevitable AB at 18w6d. No additional antepartum complications noted. Patient progressed to complete with expectant management. Patient remained in current room. Infant spontaneously delivered over intact perineum. No cardiac motion was noted on delivery. Placenta in situ. No anesthesia used. No complications noted.. EBL: 500 mL. Fundus firm. Instruments and Raytecs .
SuperCoder Answered Mon 01st of April, 2019 03:03:49 AM
Abortion can lead to multiple coding scenarios as per type of abortion and mode of management. Below mentioned are the scenarios:
If the patient presents with complete spontaneous abortion, no products of conception remain in the uterus. You would likely report an E/M code (99201-99215, Office or other outpatient visit ...) because he doesn't perform any type of procedure to treat the patient's symptoms.
If the patient has an incomplete spontaneous abortion, however, she would still have products of conception retained, though they may be expected to pass naturally without surgical intervention. If the products of conception do not evacuate on their own, the ob-gyn may perform a dilation and curettage (D&C). In this case, you would submit 59812 (Treatment of incomplete abortion, any trimester, completed surgically) with the incomplete spontaneous abortion diagnosis code
But, if the patient has a missed abortion, products of conception always remain in the uterus. As with incomplete spontaneous abortions, the ob-gyn may have to evacuate a dead embryo or fetus from the uterus through D&C. But in the case of missed abortions, you would report 59820 (Treatment of missed abortion, completed surgically; first trimester) or 59821 (... second trimester) instead of 59812 because 59820-59821 more specifically describe the service performed.