Ob-Gyn Coding Alert

Question: A pregnant patient presents at 21 weeks with a fetal demise. Our ob-gyn wants to charge for delivery but the fetus was only 21 weeks. This is the op note:
Patient received second dose of 200 microgram of Cytotec at 3:30, and she started to have uterine contractions and expelled the whole gestational sac with placenta attached to it. Membrane was intact, and the baby was inside. Uterus was palpated and found to be well contracted. Small clot was removed from the vagina. The sac was opened and the fetus was inside with the cord wrapped around one arm and the neck. Patient tolerated the procedure well and was transferred to postpartum floor.

I-m thinking that if I use the incorrect diagnosis, the insurance company will deny it. Should I use 632 (missed AB) instead of 656.4 (fetal death intrauterine 22 weeks and after)?

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Answer: The answer depends on who you ask. According to the American College of Obstetricians and Gynecologists (ACOG) guidelines, you can bill a pregnancy delivered vaginally after 20 weeks 0 days as a delivery rather than an induced abortion. You would need to indicate a diagnosis code of 632 (Missed abortion), however, because this pregnancy has not progressed to 22 weeks at this point.

You would also want to add modifier 52 (Reduced services) to the global code (59400, Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care), because the ob-gyn will have provided considerably less antepartum services.

But many payers may disagree with this opinion and may require that you bill this as an induced abortion. If this is the case with your payer, check your documentation. If the ob gave vaginal cytotec, you could 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 ob-gyn gave an oral drug to induce labor instead, you would be reporting this as a medical induction using an E/M service (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient -) and possibly prolonged physician services, if your ob-gyn also documents it (+99354-+99357, Prolonged physician service with direct [face-to-face] patient contact -).