Internal Medicine Coding Alert

Published on Thu May 08, 2014 PDF

Question: One of our physicians recently saw a patient who had had an abortion. What diagnosis codes do I use for status post abortion to support this visit?

Nevada Subscriber

Answer: An abortion is typically coded using the appropriate diagnosis code from the code range, 634-638 (Other pregnancy with abortive outcome). The appropriate code within that range will depend, in part, on the nature of the abortion (spontaneous, legal, illegal, unspecified, or failed attempt).

Note that these codes require a fourth and fifth digit to further identify the nature of the encounter. The fourth digit identifies associated complications, and the fifth digit identifies the stage. The three stages that get identified by the fifth digit include:

• 0- Unspecified
• 1 - Incomplete
• 2 – Complete

If your clinician saw the patient after the date of the abortion, you should not use a code from the 634-638 range. Instead, in such a scenario, you will likely use a code in the category of 639 (Complications following abortion and ectopic or molar pregnancies). According to ICD-9, this category is provided for use when it is required to classify separately the complications classifiable to the fourth digit level in categories 634-638. An example is when the complication itself was responsible for an episode of medical care, the abortion itself having been dealt with at a previous episode. This sounds to be the case in your scenario, and an appropriate code in the 639 series (which requires a fourth digit) will likely support the visit, assuming that was the focus of the encounter.