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.
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.