Hi all! Looking for urgent assistance with billing on this procedure! I found out about this late since I was out on surgery 
and now I am in a crunch.
This is a first having this scenario presented by one of my providers. Patient came in to the office the day prior to this occuring where patient underwent pre-induction Digoxin and Mifeprestone for abortion. Patient present to the hospital the next day with rupture of membranes and in labor. Later that day she underwent a D&C for retained placenta by the same provider as the delivery. Patient was admitted under IP status. The H&P and OP reports are listed below. I am not sure if this would be coded under 59851 or if the delivery is billed as an E/M with 59160 for the D&C as suggeted by the provider. Thanks for any help in advance!
H&P:
Chief Complaint:
bleeding/leakage of fluid
History of Present Illness
26 yo G4P1111 @15w3d by 13w2d ultrasound s/p digoxin and mifepristone on 3/22 presenting with bleeding and leakage of fluid. She reports a gush of fluid earlier this evening along with vaginal bleeding. Additionally reports intermittently painful cramping. Her cramping was severe at home, has improved somewhat on the ambulance to the hospital. She is scheduled to present in the morning for an induction. Denies dizziness, lightheadedness, CP, SOB.
PMH: Asthma
PSH: None
Meds: Albuterol PRN
All: NKDA
SH: Denies x3
Review of Systems
General: denies dizziness, fever, fatigue
Resp: denies shortness of breath, wheezing
Card: denies palpitations, chest pain
GI: denies vomiting, diarrhea. Endorses nausea.
GU: denies hesitancy, incomplete voiding, and increased frequency
GYN: denies abnormal vaginal discharge
Psych: denies anxiety depression
Consolidated Problems/Medical History
Ongoing
Asthma
Morbid obesity
Historical
Patient currently pregnant
Pregnancy
Pregnant
Pregnant
Procedure History
Smoking Status
Unknown if ever smoked
Alcohol - Denies Alcohol Use
None
Electronic Cigarette/Vaping
E-Cigarette Use: Never.
Employment/School - Not employed or in school
Home/Environment
Lives with Father, Mother, Siblings. Smoker in household: No. Feels unsafe at home: No. Safe place to go: Yes. Family/Friends available for support: Yes.
Nutrition/Health - High Risk
Regular
Sexual - Medium Risk
Substance Abuse - Denies Substance Abuse
None
Tobacco - Denies Tobacco Use
Never (less than 100 in lifetime)
Family History
Asthma: Sister, Brother, Brother, Brother, Brother, Brother and Brother.
Breast cancer: Mat Grandmother.
Epilepsy: Father.
Scoliosis..: Brother.
Health Status Family Member(s)
Pat Grandmother: History is unknown
Mother: History is unknown
Sister: History is negative
Sister: History is negative
Sister: History is negative
Mat Grandfather: History is unknown
Pat Grandfather: History is negative
Obstetrical/Gynecological History
Gravida Para Information:
Gravida: 3
Para Term: 1
Para Preterm: 0
Para Abortions: 2
Para Living: 1
Pregnancy
Pregnancy History G3 P1(1,0,2,1)
Pregnancy # 1
Baby 1 Outcome Date: 10/04/2015 Neonate Outcome: Fetal Death
Outcome or Result: Vaginal
Gender: Female Gest Age: 19 weeks 3 days Wt: --
Hospital: WCHOB Len Labor: --
Child's Name: -- Baby's Father: --
Comment: Pt woke up and was bleeding; dilated and delivered.
Chorioamnioitis per pathology
Pregnancy # 2
Baby 1 Outcome Date: 03/04/2016 Neonate Outcome: Fetal Death
Outcome or Result: Vaginal
Gender: Female Gest Age: 17 weeks 4 days Wt: 113 g
Hospital: WCHOB Len Labor: --
Child's Name: -- Baby's Father: --
Anesthesia Type: None
Comment: Chorioamnioitis per pathology
Pregnancy # 3
Baby 1 Outcome Date: 09/05/2022 Neonate Outcome: Live Birth
Outcome or Result: Vaginal
Gender: Female Gest Age: 39 weeks Wt: 2540 g
Hospital: -- Len Labor: 16 hr 25 min
Child's Name: -- Baby's Father: --
Neonate Complications: Caput; Size, small for gestational age
Maternal HIV Testing Information
A. [x] This patient has undergone HIV testing during this pregnancy
B. [] This patient has undergone HIV testing prior but not during this pregnancy
C. [] This patient has not undergone previous HIV testing
D. [] No HIV testing information available
E. [] Patient refused testing
Exposure to Contagious Disease
[] Tuberculosis
[] Hepatitis
[] Parvovirus
[] Rubella
[] Measles
[] Mumps
[] Chicken Pox
[] Influenza
[] HIV
[] Other []
Intake and Output
Last Oral Intake
Last Fluid Intake: 03/23/24 19:18:00 (03/23/24 19:16:00)
Vitals & Measurements
HR: 72 (Peripheral) RR: 18 BP: 113/60(Cuff) WT: 107.50 kg (Dosing)
Pulse Rate, Peripheral: 72 bpm (03/23/24 19:16:00)
Height/Length Dosing: 152.4 cm (03/23/24 19:16:00)
Body Mass Index Dosing: 46.28 kg/m2 High (03/23/24 19:16:00)
Objective/Physical Examination
General: No acute distress. Alert and oriented.
Heart: Well perfused
Lungs: Non-labored breathing.
Abdomen: Soft, non-distended, non tender
Neuro: No gross motor or sensory deficit
Vulva: Normal external female genitalia. No lesions visualized
Vagina: Pink, well rugated vaginal mucosa. Pooling blood tinged fluid in vault. No lesions visualized.
Cervix: Not visualized
Rectum: No external lesions visualized.
SCE: 5/50/+2, fetal parts palpable in vagina
Assessment/Plan
26 yo G4P1111 @15w3d by 13w2d ultrasound s/p digoxin and mifepristone on 3/22 admitted with rupture of membranes/ labor for delivery.
- s/p digoxin, mifepristone on 3/22
- Plan to let pt progress, push with urge
Procedure 1:
Pre-Delivery Diagnosis
26yo G4P1111 @15w3d by 13w2d ultrasound s/p digoxin and mifepristone on 3/22 admitted with rupture of membranes/ labor.
Gestational Age
@15w3d
Risk Factors
undesired pregnancy
Method of Delivery
Plan of Care regarding intrapartum management and delivery options including risks and benefits discussed with patient/family
[x] Yes
[] No
Presentation
[x] Vertex
[] Breech
[] Other []
Delivery
[x] Vaginal Delivery
[] Vacuum
[] Forceps
Vaginal Birth After Cesarean
[x] NA
[] Successful
[] Failed
Episiotomy
[x] NA
Lacerations/Extensions
[x] NA
Specimens to Pathology
None
Estimated Blood Loss
QBL 453cc
Intravenous Fluids Infused
LR
Anesthesia
IV Dilaudid
Complications
[x] NA
Vacuum Extraction
[] Soft Cup
[] Other []
Pressure Range During Contractions
[] 38-58 cm mercury (15-23 inches of mercury) during contractions
[] Other []
Pressure Range Between Contractions
[] 10-12.5 cm mercury (4-5 inches of mercury) during contractions
[] Other []
Post Delivery Infant Data
Sex
No qualifying data available.
Date/Time of Birth
No qualifying data available.
Weight
No qualifying data available.
1 Minute
No qualifying data available.
5 Minutes
No qualifying data available.
Amniotic Fluid
No qualifying data available.
Suction of the Fetal Nares and Mouth while the Fetal Head is Delivered on the Perineum
[] Bulb Suction
[] French Catheter
Condition of Newborn
demised
Condition of Mother
stable
Additional Information
26yo G4P1111 @15w3d by 13w2d ultrasound s/p digoxin and mifepristone on 3/22 admitted with rupture of membranes/ labor. With maternal effort, fetus delivered over intact perineum. No signs of life were noted. The cord was clamped and cut. Placenta was left in situ and 1000mcg misoprostol was given. buccally. Bleeding noted to be minimal.
Procedure 2:
Indication for Surgery
26 yo G4P1211 with retained placenta. After counselling patient of options of bedside extraction vs OR with anesthesia, patient elected to proceed with D&C under anesthesia.
Preoperative Diagnosis
retained placenta
Postoperative Diagnosis
retained placenta
Name of Operation
Dilation and Curettage
Description of Operation Performed, Including Technique
The risks benefits and alternatives of the procedure were reviewed with the patient. The risks of the procedure include possible injury to internal organs and intra-abdominal bleeding were discussed. The patient agreed and consented to the procedure.
Patient was taken to the operating room and placed on the operating table in a supine position. General anesthesia was initiated by anesthesia. The patient was placed in the dorsal lithotomy position with Allen-type stirrups. The patient was prepared with betadine and draped in usual fashion.
The remainder of the procedure was done under ultrasound guidance.
A weighted speculum and Lucy retractor were placed into the vagina and the placenta was visualized in the vagina. The placenta was grasped with the Bier forceps and gently removed from the vagina. The cervix was then visualized and the anterior lip of the cervix was grasped with the ring forceps.
A 10mm flexible suction curette was used and connected to the MVA device and was placed in the cervix and a suction curettage was performed. Multiple passes were made with the suction curettage under ultrasound guidance until good grit was noted. and a thin endometrial stripe was visualized on ultrasound. The cervix was noted to be slowly bleeding. The patient was given 1g tranexamic acid a bimanual massage was performed. The bleeding was then noted to have resolved. All instrumentation was removed from the vagina.
The patient tolerated the procedure well. The instrument and sponge counts were correct times two. The patient was awakened from general anesthesia and taken to her Labor and Delivery room in a stable condition.
Findings
Normal external female genitalia
Normal appearing placenta c/w gestational age
Specimen(s)
Placenta
Complications
None
Is there a planned return to the operating room?
[] Yes
[x] No
and now I am in a crunch.This is a first having this scenario presented by one of my providers. Patient came in to the office the day prior to this occuring where patient underwent pre-induction Digoxin and Mifeprestone for abortion. Patient present to the hospital the next day with rupture of membranes and in labor. Later that day she underwent a D&C for retained placenta by the same provider as the delivery. Patient was admitted under IP status. The H&P and OP reports are listed below. I am not sure if this would be coded under 59851 or if the delivery is billed as an E/M with 59160 for the D&C as suggeted by the provider. Thanks for any help in advance!
H&P:
Chief Complaint:
bleeding/leakage of fluid
History of Present Illness
26 yo G4P1111 @15w3d by 13w2d ultrasound s/p digoxin and mifepristone on 3/22 presenting with bleeding and leakage of fluid. She reports a gush of fluid earlier this evening along with vaginal bleeding. Additionally reports intermittently painful cramping. Her cramping was severe at home, has improved somewhat on the ambulance to the hospital. She is scheduled to present in the morning for an induction. Denies dizziness, lightheadedness, CP, SOB.
PMH: Asthma
PSH: None
Meds: Albuterol PRN
All: NKDA
SH: Denies x3
Review of Systems
General: denies dizziness, fever, fatigue
Resp: denies shortness of breath, wheezing
Card: denies palpitations, chest pain
GI: denies vomiting, diarrhea. Endorses nausea.
GU: denies hesitancy, incomplete voiding, and increased frequency
GYN: denies abnormal vaginal discharge
Psych: denies anxiety depression
Consolidated Problems/Medical History
Ongoing
Asthma
Morbid obesity
Historical
Patient currently pregnant
Pregnancy
Pregnant
Pregnant
Procedure History
- Removal Cerclage Cervical (n/lat) (08/27/2022)
- Cervical Cerclage (n/lat) (03/07/2022)
- No Surgical Medical History
Smoking Status
Unknown if ever smoked
Alcohol - Denies Alcohol Use
None
Electronic Cigarette/Vaping
E-Cigarette Use: Never.
Employment/School - Not employed or in school
Home/Environment
Lives with Father, Mother, Siblings. Smoker in household: No. Feels unsafe at home: No. Safe place to go: Yes. Family/Friends available for support: Yes.
Nutrition/Health - High Risk
Regular
Sexual - Medium Risk
Substance Abuse - Denies Substance Abuse
None
Tobacco - Denies Tobacco Use
Never (less than 100 in lifetime)
Family History
Asthma: Sister, Brother, Brother, Brother, Brother, Brother and Brother.
Breast cancer: Mat Grandmother.
Epilepsy: Father.
Scoliosis..: Brother.
Health Status Family Member(s)
Pat Grandmother: History is unknown
Mother: History is unknown
Sister: History is negative
Sister: History is negative
Sister: History is negative
Mat Grandfather: History is unknown
Pat Grandfather: History is negative
Obstetrical/Gynecological History
Gravida Para Information:
Gravida: 3
Para Term: 1
Para Preterm: 0
Para Abortions: 2
Para Living: 1
Pregnancy
Pregnancy History G3 P1(1,0,2,1)
Pregnancy # 1
Baby 1 Outcome Date: 10/04/2015 Neonate Outcome: Fetal Death
Outcome or Result: Vaginal
Gender: Female Gest Age: 19 weeks 3 days Wt: --
Hospital: WCHOB Len Labor: --
Child's Name: -- Baby's Father: --
Comment: Pt woke up and was bleeding; dilated and delivered.
Chorioamnioitis per pathology
Pregnancy # 2
Baby 1 Outcome Date: 03/04/2016 Neonate Outcome: Fetal Death
Outcome or Result: Vaginal
Gender: Female Gest Age: 17 weeks 4 days Wt: 113 g
Hospital: WCHOB Len Labor: --
Child's Name: -- Baby's Father: --
Anesthesia Type: None
Comment: Chorioamnioitis per pathology
Pregnancy # 3
Baby 1 Outcome Date: 09/05/2022 Neonate Outcome: Live Birth
Outcome or Result: Vaginal
Gender: Female Gest Age: 39 weeks Wt: 2540 g
Hospital: -- Len Labor: 16 hr 25 min
Child's Name: -- Baby's Father: --
Neonate Complications: Caput; Size, small for gestational age
Maternal HIV Testing Information
A. [x] This patient has undergone HIV testing during this pregnancy
B. [] This patient has undergone HIV testing prior but not during this pregnancy
C. [] This patient has not undergone previous HIV testing
D. [] No HIV testing information available
E. [] Patient refused testing
Exposure to Contagious Disease
[] Tuberculosis
[] Hepatitis
[] Parvovirus
[] Rubella
[] Measles
[] Mumps
[] Chicken Pox
[] Influenza
[] HIV
[] Other []
Intake and Output
Last Oral Intake
Last Fluid Intake: 03/23/24 19:18:00 (03/23/24 19:16:00)
Vitals & Measurements
HR: 72 (Peripheral) RR: 18 BP: 113/60(Cuff) WT: 107.50 kg (Dosing)
Pulse Rate, Peripheral: 72 bpm (03/23/24 19:16:00)
Height/Length Dosing: 152.4 cm (03/23/24 19:16:00)
Body Mass Index Dosing: 46.28 kg/m2 High (03/23/24 19:16:00)
Objective/Physical Examination
General: No acute distress. Alert and oriented.
Heart: Well perfused
Lungs: Non-labored breathing.
Abdomen: Soft, non-distended, non tender
Neuro: No gross motor or sensory deficit
Vulva: Normal external female genitalia. No lesions visualized
Vagina: Pink, well rugated vaginal mucosa. Pooling blood tinged fluid in vault. No lesions visualized.
Cervix: Not visualized
Rectum: No external lesions visualized.
SCE: 5/50/+2, fetal parts palpable in vagina
Assessment/Plan
26 yo G4P1111 @15w3d by 13w2d ultrasound s/p digoxin and mifepristone on 3/22 admitted with rupture of membranes/ labor for delivery.
- s/p digoxin, mifepristone on 3/22
- Plan to let pt progress, push with urge
Procedure 1:
Pre-Delivery Diagnosis
26yo G4P1111 @15w3d by 13w2d ultrasound s/p digoxin and mifepristone on 3/22 admitted with rupture of membranes/ labor.
Gestational Age
@15w3d
Risk Factors
undesired pregnancy
Method of Delivery
Plan of Care regarding intrapartum management and delivery options including risks and benefits discussed with patient/family
[x] Yes
[] No
Presentation
[x] Vertex
[] Breech
[] Other []
Delivery
[x] Vaginal Delivery
[] Vacuum
[] Forceps
Vaginal Birth After Cesarean
[x] NA
[] Successful
[] Failed
Episiotomy
[x] NA
Lacerations/Extensions
[x] NA
Specimens to Pathology
None
Estimated Blood Loss
QBL 453cc
Intravenous Fluids Infused
LR
Anesthesia
IV Dilaudid
Complications
[x] NA
Vacuum Extraction
[] Soft Cup
[] Other []
Pressure Range During Contractions
[] 38-58 cm mercury (15-23 inches of mercury) during contractions
[] Other []
Pressure Range Between Contractions
[] 10-12.5 cm mercury (4-5 inches of mercury) during contractions
[] Other []
Post Delivery Infant Data
Sex
No qualifying data available.
Date/Time of Birth
No qualifying data available.
Weight
No qualifying data available.
1 Minute
No qualifying data available.
5 Minutes
No qualifying data available.
Amniotic Fluid
No qualifying data available.
Suction of the Fetal Nares and Mouth while the Fetal Head is Delivered on the Perineum
[] Bulb Suction
[] French Catheter
Condition of Newborn
demised
Condition of Mother
stable
Additional Information
26yo G4P1111 @15w3d by 13w2d ultrasound s/p digoxin and mifepristone on 3/22 admitted with rupture of membranes/ labor. With maternal effort, fetus delivered over intact perineum. No signs of life were noted. The cord was clamped and cut. Placenta was left in situ and 1000mcg misoprostol was given. buccally. Bleeding noted to be minimal.
Procedure 2:
Indication for Surgery
26 yo G4P1211 with retained placenta. After counselling patient of options of bedside extraction vs OR with anesthesia, patient elected to proceed with D&C under anesthesia.
Preoperative Diagnosis
retained placenta
Postoperative Diagnosis
retained placenta
Name of Operation
Dilation and Curettage
Description of Operation Performed, Including Technique
The risks benefits and alternatives of the procedure were reviewed with the patient. The risks of the procedure include possible injury to internal organs and intra-abdominal bleeding were discussed. The patient agreed and consented to the procedure.
Patient was taken to the operating room and placed on the operating table in a supine position. General anesthesia was initiated by anesthesia. The patient was placed in the dorsal lithotomy position with Allen-type stirrups. The patient was prepared with betadine and draped in usual fashion.
The remainder of the procedure was done under ultrasound guidance.
A weighted speculum and Lucy retractor were placed into the vagina and the placenta was visualized in the vagina. The placenta was grasped with the Bier forceps and gently removed from the vagina. The cervix was then visualized and the anterior lip of the cervix was grasped with the ring forceps.
A 10mm flexible suction curette was used and connected to the MVA device and was placed in the cervix and a suction curettage was performed. Multiple passes were made with the suction curettage under ultrasound guidance until good grit was noted. and a thin endometrial stripe was visualized on ultrasound. The cervix was noted to be slowly bleeding. The patient was given 1g tranexamic acid a bimanual massage was performed. The bleeding was then noted to have resolved. All instrumentation was removed from the vagina.
The patient tolerated the procedure well. The instrument and sponge counts were correct times two. The patient was awakened from general anesthesia and taken to her Labor and Delivery room in a stable condition.
Findings
Normal external female genitalia
Normal appearing placenta c/w gestational age
Specimen(s)
Placenta
Complications
None
Is there a planned return to the operating room?
[] Yes
[x] No
