Wiki 59812 vs 58210

[smobleybraun]

Pt presented over one month ago for an abortion that was treated medically vs surgically. Pt recently returned for the Essure sterilzation procedure. At that time, the physician found that the utertine lining was still thick and performed a D&C before doing the Essure procedure. The physician thinks the D&C should be coded as surgical treatment of an incomplete abortion though there were no retained products of conception. I think coding a non-ob D&C would be more appropriate. Please advise.

Thanks in advance!

 

[bonzaibex]

I would be inclined to code the D&C based on the doctor's diagnosis. If he diagnoses an incomplete abortion on that procedure, then the D&C code needs to match. If the procedure and diagnosis code don't mesh, you're apt to get a denial from the carrier.

Becky, CPC

 

[preserene]

59812 vs 58210:

59812 vs 58210:
Why would you code for non ob D.&C? at one month ago pregnancy and abortion History?
Well, you can still think of trophoblastic diseases ; yet it can be placed in OB related .this case more commonly, logically can be taken as a suspected remnants. More over, the physician can choose for either check curettage or diagnostic and theuputic as well to make sure the cavity is clear; the date of this D&C is with the ‘period of POSTABORTION'
As per the history date and procedures you provided, the patient is still in the post abortal period. It is same like the purperium , we count 42 days to place them in purperium/post abortal period. Any complication during that period should be counted and related to abortion-here in your case it can be viewed as “Incomplete Abortion”
So, 59812:-- Treatment of incomplete Abortion, any trimester, completed surgically - is appropriate for reporting ( as per my openion)
Code number 58120 (not 58210 which does not apply; I do understand it is a typing error from you), which is a nonobtetrical, can be differed in reporting in your case, unless your doctor wants so.
I hope that I am clear.

I do agree with Becky; it is your doctor's diagnosis code that counts on in this much and you can always verify with your physician if a doubt arise on the point as I discussed.
Not documented by the physician, IT NEVER HAPPENED- rule No.1 !!
Thank you.

 

[smobleybraun]

Thanks for the information. From where are you quoting the specific "post-abortion period" time frame of 42 days? I looked extensively for that info, but had no luck

Thank you!

 

[preserene]

I would reinstate from my knowledge that for all clinical, practical and statistical purposes what holds good for 'Puerperal Period(42days) holds good for postabortal Period- both incidental to pregnancy. Please verify with any OBGYN authorities, especially your case under discussion.
Thank you