Ob-Gyn Coding Alert

“Complete” or “incomplete” may decide your CPT^® coding options.

If you have a claim for abortion on your desk, you may be wondering how to navigate abortion diagnoses, and you should allow your physician’s documentation be your guide.

Generally, you will designate nonelective abortions at fewer than 22 weeks gestation as spontaneous incomplete (O03.0-O03.2, O03.3-, O03.4), spontaneous complete (O03.5-O03.7, O03.8-, O03.9) or missed abortion (O02.1). Although technological advances enable physicians to detect pregnancy in its earliest stages, coding for nonelective abortions has become more complicated, says Melanie Witt, RN, MA,  an independent coding consultant in Guadalupita, N.M.

When a patient presents with no prior pregnancy diagnosis, the ob-gyn can use tools such as ultrasound and beta subunit HCG (human chorionic gonadotropin, a pregnancy test that helps determine the stage of pregnancy) to confirm pregnancy and decide how far it has progressed. When a patient presents with a nonelective abortion, diagnosis and procedural coding can be a challenge, especially if the pregnancy terminated very early on.

Women frequently do not seek medical attention for a delayed menstrual cycle because they may not be aware that conception occurred. If the ob-gyn diagnoses a pregnancy and it later terminates, either spontaneously or by induction, you should report the related physician services. And the diagnosis coding can be critical to ensuring proper payment for the doctor’s work.

Patient’s Dx Will Affect Your CPT^® Coding

When determining the correct CPT^® code for treating a nonelective abortion, the first question you should ask is whether the ob-gyn performed surgery to complete the process.

If the patient presents with a complete spontaneous abortion, no products of conception remain in the uterus. You would likely report an E/M code (99201-99215, Office or other outpatient visit ...) because he doesn’t perform any type of procedure to treat the patient’s symptoms, coding experts say. You would link the E/M service to the appropriate O03.5-O03.9 code on the CMS-1500 form.

If the patient has an incomplete spontaneous abortion, however, she would still have products of conception retained, though they may be expected to pass naturally without surgical intervention. If the products of conception do not evacuate on their own, the ob-gyn may perform a dilation and curettage (D&C). In this case, you would submit 59812 (Treatment of incomplete abortion, any trimester, completed surgically) with the incomplete spontaneous abortion diagnosis, such as O03.4 (Incomplete spontaneous abortion without complication).

But if the patient has a missed abortion, products of conception always remain in the uterus. As with incomplete spontaneous abortions, the ob-gyn may have to evacuate a dead embryo or fetus from the uterus through D&C. But in the case of missed abortions, you would report 59820 (Treatment of missed abortion, completed surgically; first trimester) or 59821 (... second trimester) instead of 59812 because 59820-59821 more specifically describe the service performed. In this case, you would link the procedure code to O02.1.

Note that 59820 has a 90 day global period. This means that while you may report E/M services for care prior to the discovery of the missed abortion, and the E/M the day of or day before the surgery that was related to the decision to do surgery (appending a modifier 57 (Decision for Surgery)), all subsequent E/M services related to recovery from this surgery are included for 90 days, says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wis.

The spontaneous incomplete and missed abortion diagnoses indicate that retained products of conception required surgical removal. And a complete spontaneous abortion ICD-10 code implies that there are no retained products of conception, and therefore you shouldn’t report a procedure code.

Bonus Challenge: What About Abnormal Products?

Occasionally, a patient enters the exam room unaware that she is pregnant, and the diagnosis is something other than a missed abortion. In this case, special procedural codes apply.

Follow This Guide to Abortion Terminology

With so many different types of abortion, knowing the medical terminology is essential to coding related services based on your ob-gyn’s documentation. By being familiar with these common types of abortions, you take the first step to assigning the correct ICD-10 and CPT^® codes:

• Complete — The complete expulsion or extraction from its mother of a fetus or embryo; complete expulsion from the uterus of any other product of conception (for example, blighted ovum).
• Elective —  Without medical justification but performed in a legal way.
• Incomplete — Part of the products of conception have been passed, but part (usually the placenta) remains in the uterus.
• Induced — Expulsion of the fetus and products of conception brought on purposefully by drugs or mechanical means.
• Inevitable — Characterized by rupture of the membranes in the presence of cervical dilation in a previable pregnancy.
• Missed — Death of the fetus in utero prior to 22 weeks, with retention of the products of conception
• Septic — An infectious abortion complicated by fever, endometriosis or parametritis.
• Spontaneous — An abortion that has not been induced artificially. This term is usually limited to pregnancies of less than 22 weeks gestation.
• Therapeutic — interruption of pregnancy before the 20th completed week of gestation for legally acceptable, medically approved indications.

For example, the ob-gyn performs a dilation and curettage (D&C) for a blighted ovum (O02.0, Blighted ovum and nonhydatidiform mole). In this case, the nonobstetrical D&C code (58120, Dilation and curettage, diagnostic and/or therapeutic [nonobstetrical]) doesn’t seem right. The correct code, rather, depends on when—or if—the ob-gyn discovered the blighted ovum and pregnancy.

The treatment for a blighted ovum, which is a fertilized egg that fails to develop into a fetus, may be the same as a missed abortion, but only if the doctor has confirmed a pregnancy. For example, a patient may come in with unexplained vaginal bleeding before she realizes that she may have been pregnant, and a pregnancy test comes back negative. If this is the case, and there is a negative pregnancy test, you should report 58120 even if the pathology report indicates a blighted ovum after the fact.

On the other hand, if the ob-gyn has diagnosed the patient as pregnant either prior to or at the same visit and she begins to bleed, she may spontaneously abort, or she may require surgery to remove the retained products of conception. The blighted ovum may not become apparent until the pathology report comes back, but because there was a positive pregnancy test, you should report 59812 (Treatment of incomplete abortion, any trimester, completed surgically).

Although unusual, a patient with a blighted ovum may only complain of a missed period. The ob-gyn will likely order a pregnancy test and perform an ultrasound. If the pregnancy test is positive, and the ultrasound reveals a blighted ovum (but no symptoms of abortion, for example, discharge or bleeding), the physician will likely perform a D&C. In this case, you would report 59820 or 59821 with O02.0. Because the patient has a positive pregnancy test, you must code the ultrasound as 76801 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation) because the provider is evaluating the status of the pregnancy.

With a blighted ovum, you are not inducing an abortion because there is no embryo or fetus present in the gestational sac. Rather, you may be helping along what nature has already started.