Ob-Gyn Coding Alert

Question: A patient came to the hospital with pelvic pressure and pain at 18 weeks. The U/S results showed prolapsing membranes. After a physician/patient discussion, the patient decided to let nature take its course. The Patient admitted for an attempt at stopping labor and antibiotics and tocolytics were given. The Patient had an incompetent cervix and the baby delivered in her hospital room bathroom while the patient was on the toilet with physician out of the room. Five attempts were made to deliver the placenta that was half in and out of cervix with no luck. The physician took patient to the operating room to try to tease out the placenta, but was still not able to get it out. So he placed her in stirrups and grasped placenta with a ring clamp and teased it out of the cervix. He then did a D&C to ensure there was no residual POC left. Can I start with billing an observation code 99235? He had been monitoring her for several hours; delivery of placenta; and doing the D&C? 

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Answer: At 18 weeks, you cannot bill a delivery of anything, including a placenta. In this case, you have an incomplete abortion that took place with prior treatment to try and prevent it. You will be billing 59812-22 (Treatment of incomplete abortion, any trimester, completed surgically; Increased procedural service) for the surgical treatment of the incomplete abortion — which, in this case, included teasing the placenta out followed by curettage. The documentation should support adding the modifier 22 in this case.

If she were admitted and then discharged on the same date of service, code 99235 would be appropriate if the documentation supported this level of service. If she was simply admitted after a period of observation on the same date of service, you should only bill the admission (99222, Initial hospital care, per day, for the evaluation and management of a patient …). To get it paid (instead of bundled into 59812) you will need to add a modifier 57 (Decision for surgery) because 59812 has a 90-day global period.

The documentation might also support prolonged services that day as well (+99356 and +99357). No modifiers are required because these are add-on code that can only be billed with an E/M problem service. 

All of the care following the D&C would not be billed, as you are now in the global days for 59812.