Ob-Gyn Coding Alert

Ob-gyn coders often report pregnancies that do not carry to term. Specific procedural codes come into play in cases more complicated than spontaneous abortion, and diagnostic coding depends on where the line is drawn between fetal demise and intrauterine death.
 
Although ICD-9 draws the line at 22 weeks gestation for early fetal loss (no delivery procedure implied), the age of the fetus will determine whether the service can be billed as delivery of a missed abortion rather than medical management of an induced abortion. The policy of the American College of Obstetricians and Gynecologists (ACOG) differs slightly: It considers the service a delivery and not treatment of a missed abortion (even if missed abortion code 632 is reported) if the fetus was 20 weeks/0 days or older and delivered vaginally through induced labor.

Coding Scenario

Tammy Langley, insurance specialist for San Dimas Medical Group in Bakersfield, Calif., presents the following scenario: a case of fetal demise at 17 weeks for a previous cesarean section patient returned to the operating room for retained placenta.
 
Coding this case depends on a few variables, says Melanie Witt, RN, CPC, MA, an ob/gyn coding expert. It seems that the physician induced labor at 17 weeks gestation on a patient whose fetus had died in utero and then returned the patient to the operating room for retained placenta" " Witt says. The circumstances surrounding the inducement must be considered when coding this particular case.
 
First Witt reminds that a fetus at less than 20 weeks/0 days gestation is coded not as a delivery but according to management of the abortion (spontaneous incomplete induced or managed surgically).
 
The diagnostic code in this case is 632.
 
Witt explains the procedural coding as follows:
 
If this is a medically managed induced abortion that is Pitocin or other labor-inducing medications were used only E/M codes (not surgical abortion codes) should be reported.
 
The hospital admission and any subsequent-care days prior to fetal expulsion is coded from the 99221-99223 series.
 
If the physician spent prolonged time with the patient a prolonged service code (+99356-+99357) with documentation supporting this additional level of care could also be reported.
 
Report the patient's return to the operating room as 59812 (Treatment of incomplete abortion any trimester completed surgically). No modifier is required on the surgical code but this procedure will have follow-up days attached so that any hospital care following the procedure (including discharge management) will be included.
 
Modifier -57 (Decision for surgery) may have to be added to the hospital service code preceding the surgery to indicate when the decision to perform surgery was made.
 
If the patient was induced using one or more vaginal suppositories report 59855 (Induced abortion by one or more vaginal suppositories [e.g. prostaglandin] with or without cervical dilation [e.g. laminaria] including hospital admission and visits delivery of fetus and secundines).
 
If the patient was induced with suppositories and if the retained placenta was removed on the same day code 59856 ( with dilation and curettage and/or evacuation) instead.
 
If the return to the operating room occurred the next day bill 59855 on day one and 59812 on day two.
 
Append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to 59812 to tell the payer that you are dealing with a complication of the original procedure.
 
Note: The fact that the patient had a previous cesarean does not matter unless the physician has indicated that this might have contributed to the fetal demise.