Ob-Gyn Coding Alert

Question: While in the emergency department (ED), our gynecologist saw a 17-year-old patient who had an elective abortion elsewhere. Our gynecologist had never seen this patient before. The patient came to the ED with a fever and retained products of conception (POC). Our gynecologist performed dilation and curettage (D&C), and the patient is still hospitalized for intravenous antibiotic therapy. Should I report 59812 as the D&C procedure code, and 637.71 with 635.11 for the diagnosis codes?

Georgia Subscriber

Answer: You are correct to choose 59812 (Treatment of incomplete abortion, any trimester, completed surgically) and the linking diagnoses 637.71 (Retained products of conception following abortion, incomplete) and 635.11 (Legally induced abortion complicated by hemorrhage).

Because the question implies that the physician has never seen the patient before, you can also report an E/M service code. This will be either an emergency department visit (99281-99285) if the ED physician is not billing for it or an outpatient visit for a new patient (99201-99205) if the ED physician is billing, or an outpatient consult (99241-99245) if the ED requested a consult from your physician.

For any of these coding choices, append modifier -57 (Decision for surgery) to the E/M service to show that this was the visit at which the ob-gyn decided to perform the surgery.You should count all subsequent care as part of the postoperative care following the surgical treatment of the incomplete abortion.