Can you help us with a coding issue regarding spontaneous abortions? We are wondering if it is appropriate to code a delivery code is they say the fetus was delivered. The patient came into the hospital actively having a miscarriage, “She delivered the second trimester fetus, approximately 16 weeks”. Placenta was manually removed by the Dr. as it didn’t come out on its own.
If the physician documented the delivery it would be reported based on my research. If a different procedure were performed, i.e. D&C following delivery or abortion, that would be reported.
According to CPT® Assistant:
The definition of “abortion” is the premature expulsion from the uterus of the products of conception, the embryo or a non-viable fetus. However, for the lay person, the coding or labeling of the medical record or report as “spontaneous abortion” may be somewhat problematic. The CPT codes properly use the medical term abortion.
On the basis of the cause, abortions may be categorized as either spontaneous, the natural (with no active interference) termination of pregnancy prior to the 20th week of gestation, or induced, in which a deliberate attempt has been made to terminate the pregnancy.
Coding Clarification
The definition of “abortion” is the premature expulsion from the uterus of the products of conception, the embryo or a non-viable fetus. However, for the lay person, the coding or labeling of the medical record or report as “spontaneous abortion” may be somewhat problematic. The CPT codes properly use the medical term abortion.
On the basis of the cause, abortions may be categorized as either spontaneous, the natural (with no active interference) termination of pregnancy prior to the 20th week of gestation, or induced, in which a deliberate attempt has been made to terminate the pregnancy.
Threatened Abortion
A threatened abortion is diagnosed when vaginal bleeding occurs in the first 20 weeks of pregnancy. The differential diagnosis of this bleeding that occurs in early pregnancy in approximately 20% of all patients is usually included in the antepartum care component of “routine” obstetric care of the patient who successfully delivers. In the event that the patient being treated for a threatened abortion requires additional visits, these should be coded separately using evaluation and management services codes, according to the services the physician provides.
Spontaneous Abortion (Miscarriage)
Complete Abortion
When a spontaneous abortion that is complete (any trimester) occurs and the physician manages the patient medically, with no surgical intervention, the physician should report the appropriate level of evaluation and management code, dependent on the place where the patient is seen (99201-99233).
Incomplete Abortion
An incomplete abortion occurs when the uterus is not entirely emptied of its contents. Fragments of the products of conception may remain within the uterus, protrude from the external os of the cervix, or can be found in the vagina. Some fragments of the products of conception may have spontaneously passed out of the vagina. Code 59812 is used to report the dilation and curettage (either sharp or suction curettage) for the surgical management of an incomplete abortion. However, if the patient is septic and is diagnosed as experiencing an incomplete abortion, do not use code 59812. (See septic abortion.)
59812Treatment of incomplete abortion, any trimester, completed surgically.
ICD-9
For ICD-9 this would be 73.59 Other manually assisted delivery this code include delivery of spontaneous abortion. The separate manual removal of the placenta is coded to 75.4- Manual removal of retained placenta.
ICD-10
Manually assisted spontaneous abortion is coded as 10E0XZZ (Since the pregnancy was not artificially terminated, this is coded to Delivery, because it captures the procedure objective. The fact that it was an abortion will be identified in the diagnosis code.)
The placenta removal would be coded separately as it was manually removed 101D17ZZ- Extraction of Products of Conception, Retained, Via Natural or Artificial Opening
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