Ob-Gyn Coding Alert

Question: I have a patient who had a failed medical abortion (other provider) and so she came to us with abdominal pain. We found retained products of conception (POC). I am at a loss on how to code this. I used 59812 for treatment of incomplete abortion, and with POC still there, that was the only CPT^® that fit. For the diagnosis I used O07.4 (Failed attempted termination of pregnancy without complication), although I didn’t like it. This was denied. There just don’t seem to be any really decent diagnoses that would go with this scenario. We’re being told to bill the state (Oregon) for the abortion, but the codes are for induced abortions. We’re just dealing the POC that were not adequately removed by the other provider.

Any help you can give on coding this correctly would be very much appreciated. I’ve provided the main part of the note below

Indication for Surgery 23yr old G3P2012 s/p medical abortion with ongoing pain and concern for retained products of conception who presented for D&C.

Preoperative Diagnosis Failed medical abortion Pelvic pain

Postoperative Diagnosis Same

Operation Suction dilation and curettage

Findings 1. 8wk anteverted uterus 2. Possible retained products of conception vs organized clot

Specimen(s) Specimen ID: A. Products of conception [1]

Technique After informed and signed consent, the patient was taken to the operating room, where a huddle was performed with all appropriate surgical staff. General anesthetic was administered without difficulty. She was placed in high lithotomy position and prepped and draped in the usual sterile fashion. A pelvic examination revealed the findings above.

A bivalve speculum was placed into the vagina. A single tooth tenaculum was used to grasp the anterior lip of the cervix. Paracervical block was performed with 10ml of 0.5% Marcaine with epinephrine at 5 and 8 o’clock in the cervicovaginal junction. The cervix was dilated to 24 French with Pratt dilators. An 8mm rigid curved cannula was used to evacuate the uterine contents until a gritty texture was noted throughout.

The tenaculum was removed and the cervix was noted to be hemostatic. The speculum was removed concluding the procedure. All counts were correct. She was taken out of lithotomy position and awoken without difficulty. She was transferred to a gurney and taken to the recovery room awake, comfortable and stable.

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