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Code This!

Scenario Week of February 14, 2013:
View Current Scenario

Assign the Correct ICD-9-CM Diagnosis and CPT 2013 Procedure Codes for the Following Outpatient Coding Scenario.

PREOPERATIVE DIAGNOSIS: Missed abortion.

POSTOPERATIVE DIAGNOSIS: Missed abortion.

PROCEDURE: Suction and sharp dilation and curettage.

SURGEON: ASSISTANT: None.

ANESTHESIA: GETA.

FINDINGS: A 13-week size uterus with moderate products of conception.

COMPLICATIONS: None apparent.

ESTIMATED BLOOD LOSS: Minimal with approximately 400 mL of blood and products of conception.

URINE OUTPUT: 400 mL, clear, catheterization prior to start of the case.

IV FLUIDS: 400 mL of LR.

HISTORY OF PRESENT ILLNESS: This is a 33-year-old female who has been getting prenatal care with me. She has seen me one time. She was scheduled for an ultrasound in the clinic on October 05, 2012, for dating. She presented to the emergency room on October 02, 2012, complaining of a large gush of bloody fluid earlier in the day. She was doing well when she was seen in the emergency room without further bleeding or leaking fluid. Her cervical os was closed, and her vital signs were stable, and she had no pain. An ultrasound was performed, which was consistent with a fetal demise at 9 weeks. She was supposed to be just over 13 weeks by date. She followed up with me in the office on October 3, 2012, where a second ultrasound was performed, which did in fact confirm fetal demise. I discussed watchful waiting versus medical management versus surgical management with the patient and her husband. All questions were answered and they desired to proceed with a D and C.

PROCEDURE SUMMARY: The patient was taken to the operating room where general anesthesia was obtained without difficulty. She was prepped and draped in the usual sterile fashion and placed in the dorsal lithotomy position in Yellofin stirrups. A weighted speculum was placed in the posterior vagina, and the anterior aspect was held back with a right-angled retractor. A single-tooth tenaculum was placed in the cervix. The cervix was sequentially dilated after sounding to 12 cm. It was dilated to size 9 Hegar dilator. A size 8 suction curette was used for the procedure. Approximately 50 mmHg of pressure was used throughout the procedure. Multiple passes of the curette were required in order to remove all of the products of conception. I believe this was because of the small size of the curette. However, I felt it was not prudent to continue dilating the patient's cervix further. Sharp curette was performed periodically between suctioning. As I felt the uterus began to cramp down and saw less bleeding, I performed a final score of the uterus and felt gritty material throughout. The uterus began to shrink slightly, and bleeding was minimal. A final pass with the suction curette revealed no further products of conception. The procedure was then stopped, and all instruments were removed. The tenaculum sites were dry. There were no apparent complications, and the patient was taken to the recovery room and awakened in stable condition. Sponge, lap, and instrument counts were correct x2 at the end of the case.

Code This! Assign the correct ICD-9-CM Diagnosis and CPT 2013 Procedure Codes.


Answers:

CPT CODE(S):
59821

ICD-9-CM CODE(S):
632

RATIONALE:
The medical term “abortion” is defined as the early expulsion of products of conception—an embryo or a fetus that is not viable—from the uterus. CPT Assistant Fall 93:9 offers clarification to the coder by providing a description and definition for the various types of abortions described by CPT codes. Terms used in the medical record can provide confusion or difficulty for a coder new to this area of medical coding.

The term “missed ab” or “missed abortion” references a condition in which a fetus that died in the first half of the pregnancy has been retained for a prolonged period. In such cases, the D&C is coded according to the trimester the patient is in when the procedure is performed. The operative report indicates that the uterus size was 13 weeks but the fetal demise occurred at nine weeks. Since the procedure was performed in the second trimester, CPT code 59821 was selected.

Note: To find the code, look in the CPT index under the main term “Abortion.” A subentry exists for “missed,” under which there are two code options, including “first trimester” identified by 59820 and “second trimester” identified by 59821.

ICD-9-CM code 632 is selected by locating the main term “Abortion” in the alphabetical index and finding the subterm “missed,” which has code 632 next to it. Confirmation in the tabular index confirms that category 632 is coded to the highest degree of specificity and describes fetal demise prior to reaching 22 weeks’ gestation, including retained products of conception. No further diagnosis code is necessary.

 

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