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Ob-Gyn Coding Alert

READER QUESTION ~ Choose Correct Abortion Dx Every Time

Published on Fri Apr 27, 2007

Question: One of our doctors saw a patient in the emergency department (ED). Her own gynecologist previously saw her and told her she -had a spontaneous abortion- with continued bleeding, so the gynecologist did a dilation and curettage (D&C). Now our doctor came to the ED, examined her, and documented: -s/p missed AB & D&C most likely uterine atony and retained clot. Patient given Methergine,- and so on. My ob-gyn selected 632 (Missed abortion), but I think it's 634.11. Which is correct?

Wyoming Subscriber Answer: The patient does not have a missed abortion at this visit. The fetus is already gone, and now your ob-gyn is dealing with the retained products of conception. The correct diagnosis code for this encounter is 634.11 (Spontaneous abortion; complicated by delayed or excessive hemorrhage; incomplete), no matter what your physician thought was the original problem (missed versus spontaneous abortion).

Heads up: A missed abortion is one in which the fetus is dead but the patient has not yet gone into labor, and your physician muse remove the fetus surgically or induce labor.
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